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BACKGROUND: Triplane fractures are rare enough that large homogeneous series to support management decisions are lacking. During initial evaluation, the addition of computed tomography (CT) to conventional X-rays (XR) does not always alter the patient's clinical course. Therefore, routine use of CT is controversial. This study aims to: (1) clarify quantitative relationships between articular displacement measured on XR versus CT and (2) identify whether metaphyseal displacement on the lateral XR predicts clinically relevant articular displacement on a CT scan. METHODS: A 10-year retrospective review of consecutive triplane fractures was performed at a level 1 pediatric trauma center. Maximum articular and metaphyseal displacement were recorded from XR and CT. Quantitative relationships between XR and CT measurements were compared among imaging modalities and radiographically operative versus nonoperative fractures. RESULTS: Eighty-seven patients met the inclusion criteria. XR underestimated articular displacement by 229% in the sagittal plane (1 mm on XR vs 3.3 mm on CT; P < 0.05) and 17% in the coronal plane (2.3 mm on XR vs 2.7 mm on CT; P < 0.05). XR underestimated articular step-off by 184% in the coronal plane and 177% in the sagittal plane ( P < 0.05). CT measurements more often differentiated patients who did or did not undergo surgery at our institution. Metaphyseal displacement was significantly higher in patients with traditionally operative articular displacement (≥2.5 mm on CT) versus those with articular displacement below traditionally operative thresholds (2.4 vs 0.9 mm, P = 0.001). Sixty patients had metaphyseal displacement >1 mm on the lateral XR, of whom 56 had surgical-magnitude articular displacement (≥2.5 mm) on CT (positive predictive value = 94%). CONCLUSIONS: Conventional radiographs underestimate the true articular displacement of triplane fractures. Surgical-magnitude articular step-off is rare, and the largest articular gap is usually visualized on the axial CT image. Metaphyseal displacement >1 mm, which is easily measured on a lateral XR, is strongly predictive of clinically relevant articular displacement on CT. This radiographic finding should prompt advanced imaging before proceeding with nonoperative management. LEVEL OF EVIDENCE: Level III.

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PURPOSE: To report the incidence and morphology of ipsilateral distal articular involvement (DAI) in a consecutive series of tibial shaft fractures. METHOD: A retrospective review was performed on 115 patients who underwent intramedullary nailing for tibia shaft fractures. Ankle evaluations included preoperative radiographs and computed tomography (CT) scans in all patients. RESULTS: Thirty-two patients (27.8%) in our series presented with tibial shaft fractures associated with DAI. Tibial spiral fractures (42A1) were significantly related to DAI (RR: 1788). In 28 (87.5%; 28/32) articular fractures, posterior malleolus fractures (PMF) were present; 22 were isolated, and six (18.8%) occurred in combination with medial malleolus or anterolateral fractures. The remaining (12.5%; 4/32) were isolated medial malleolus fractures. Ten (31.2%; 10/32) articular fractures were occult on the radiographs and only detected on CT scan. CONCLUSION: DAI is common in tibial shaft fractures. CT evaluation is mandatory due to the high number of occult fractures. Although isolated PMF is the most frequent pattern of DAI involvement, 31.3% of the cases exhibited different patterns.

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Trapezium fractures are unusual; however, they represent the third most frequent fracture of the carpal bones. As they usually follow a high-energy trauma, they are associated with distal radius, Bennett, or Rolando fractures in 80% of cases. Traditional treatment options include, closed reduction and percutaneous pinning, or open reduction and internal fixation. To minimize the additional surgical trauma, an arthroscopic technique has been developed for safe, minimally invasive management of complex injuries of the first carpo-metacarpal joint. Intra-articular dislocated fracture fragments are reduced under direct visualization and fixed through small incisions. Limiting additional surgical damage on the carpo-metacarpal joint ligaments, capsule, and other soft tissues around the fracture preserves the blood supply to fracture fragments and also the proprioceptive system, which is key for the dynamic stability of such a hypermobile joint. This report confirms that the procedure is feasible, and a complete functional recovery can be expected with reduced postoperative rehabilitation.

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OBJECTIVE: To assess the quality and variability of osteochondral allograft (OCA) transplantation rehabilitation protocols associated with academic orthopedic programs in the United States. DESIGN: A systematic review was performed to collect all publicly available online rehabilitation protocols for femoral condyle OCA transplant from US academic orthopedic programs participating in the Electronic Residency Application Service. These protocols were evaluated for inclusion of different rehabilitation components as well as timing of suggested initiation of these activities. RESULTS: A total of 22 protocols were included. Although 91% of protocols recommended bracing, wide variation exists in total time of utilization. Median time for full weight bearing (FWB) was 7 weeks (range 4-8). On average, each protocol mentioned 9 (range 2-18) different strengthening exercises. The median time suggested to return to high-impact activities was 9 months (range 8-12). Only 3 protocols (14%) offered criteria of advancement for each phase as well as criteria for discharge. CONCLUSION: Very few of the academic orthopedic programs have published online rehabilitation protocols following OCA transplantation. Although there is wide variation between the protocols, it allowed the identification of trends or patterns that are more common. However, there is need for more standardized evidence-based rehabilitation protocols which are easy to understand and follow by patients.

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Background: Coxofemoral dysplasia (CFD) is the abnormal development of the hip joint, mostly affecting large breeds, and is characterized by subluxation or complete luxation of the femoral head. Among the conservative therapeutic options, cell therapies with stem cells for CFD provides potential by the countless possibilities of therapeutic application, especially those related to the chronic and/or degenerative diseases treatment, which could be a key point for the bone and joint repair. The objective was to report a bilateral CFD case in a dog, treated with intra-articular application of mesenchymal stem cells (MSC), with 0, 30, 60 and 90 days, and further evaluations. Case: A 2-year-old male Akita dog was referred to the Veterinary Hospital Harmonia (HVH) located in the city of Recife, Pernambuco, presenting clinical signs of hip pain, lameness and pelvic limbs hopping. By orthopedic examination, pain was observed at the cranial and caudal extension of the pelvic limb, and at flexion, abduction and adduction of the limb, as well as moderate muscle atrophy and presence of joint crackling. By coxofemoral radiography performed in ventrodorsal projection, it were detected bilateral femoral head subluxation, thickening of the femoral neck and the presence of intraarticular osteophytes. These findings are compatible with the degeneration caused by the presence of CFD. Laboratory tests performed such as hemogram and biochemical had no changes. Thus, the patient had intra-articular application of allogeneic MSC, derived from adipose tissue, obtained by private company. For stem cell applications, arthrocentesis of the hip joints was performed one at a time, using a 5 mL syringe and 16G needle for aspiration of 2 mL synovial fluid, for discard and application of stem cells. After aspiration, the syringe containing the MSC were fitted to the 16G needle for the implant. After the...

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Abstract Tillaux fractures are fractures of the lateral margin of the distal tibia, usually reported in children between 12 and 14 years old. As intraarticular fractures, they require anatomic reduction and fixation to avoid posttraumatic complications. Since the injury mechanism is external rotation of the foot on the leg, these injuries are commonly associated with other fractures or ligamentous lesions. Currently, arthroscopy is being increasingly used to assist and improve surgical treatment of ankle fractures. The authors describe a 12-month follow-up of a rare case of a missed Tillaux fracture associated with syndesmosis injury in a 76-year-old polytrauma patient, successfully treated by arthroscopically-assisted reduction and internal fixation.

Resumo As fraturas de Tillaux são fraturas da margem lateral da tíbia distal, geralmente relatadas em crianças entre 12 e 14 anos. Como fraturas intra-articulares, requerem redução e fixação anatômica para evitar complicações pós-traumáticas. Como o mecanismo de lesão é a rotação externa do pé na perna, essas lesões são comumente associadas a outras fraturas ou lesões ligamentares. Atualmente, a artroscopia está sendo cada vez mais utilizada para auxiliar e melhorar o tratamento cirúrgico das fraturas do tornozelo. Os autores descrevem um acompanhamento de 12 meses de um caso raro de uma fratura não percebida de Tillaux associada a lesão por sindesmose em um paciente de politrauma com 76 anos de idade, tratado com sucesso por redução e fixação interna assistida por artroscopia.

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Calcaneal fractures are the most frequent of the tarsus (3.5% of all fractures). Young adults are mainly affected, being more frequent in men (5.9:1). On the other hand, ligament injuries associated with fracture of the calcaneus are very infrequent. We describe a case of a 39 year old patient who suffered ankle trauma. He presented instability in plantar flexion and inversion. A fracture of the calcaneus was diagnosed. During surgery, a complete lesion of the lateral ligament complex was found. The reduction and osteosynthesis associated with ligament reconstruction was performed. We consider important to confirm the stability of the ankle after a calcaneus fracture. Lack of diagnosis in this type of injuries can evolve into chronic instability.

Las fracturas de calcáneo son las más frecuentes del tarso (3.5% de todas las fracturas). Afectan a adultos jóvenes, siendo más frecuentes en hombres (5.9:1). Por otro lado, las lesiones ligamentarias asociadas a fractura de calcáneo no son muy frecuentes. Presentamos un caso de un paciente de 39 años que sufrió entorsis de tobillo. Mostraba inestabilidad en flexión plantar e inversión. Radiografías mostraron una fractura de calcáneo. Durante la cirugía se evidenció una lesión completa del complejo ligamentario lateral. Se realizó la reducción y osteosíntesis asociada a la reconstrucción ligamentaria. Ante fracturas de calcáneo es importante corroborar la estabilidad del tobillo. La falta de diagnóstico en este tipo de lesiones puede generar inestabilidades crónicas.

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OBJECTIVES: The aim of this study was to describe the treatment and outcome of acetabular and other pelvic fractures in cats with patellar fracture and dental anomaly syndrome (PADS) and to provide advice on how to manage these cases in practice. METHODS: Data were collated on cats with PADS that were reported to have sustained pelvic fractures or had fractures or fissures of the pelvis identified on submitted radiographs. The details of the fractures were recorded, in addition to any treatment and outcome information. RESULTS: Of the 215 cases reported with PADS, 58 cats (27%) were found to have pelvic fractures, none of which were known to have resulted from significant trauma. There were 101 fractures in total and of these 15 were treated with surgery, including 10 acetabular fractures, two ilial, two pubic and one ischial fracture. Screw loosening and loss of fracture reduction was seen in four of the surgically treated fractures (two pubic fractures, one ilial and one acetabular fracture). Fourteen cats were euthanased as a direct result of a fracture occurring. While most pelvic fractures healed uneventfully, some cats remained intermittently lame, but it was not always possible to determine the cause of the lameness from the information available and because all cats had concurrent patellar fractures. CONCLUSIONS AND RELEVANCE: Many of the pelvic fractures healed with conservative management. Fractures involving articular surfaces such as acetabular fractures may benefit from surgical stabilisation as surgery may offer the benefits of articular fracture repair with improved joint congruency and a faster return to normal activity.

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Resumen: Introducción: Las fracturas intraarticulares de radio distal son un desafío terapéutico para el cirujano ortopedista. Hay estudios que avalan el uso de la fluoroscopía y otros promueven la artroscopia. Con este trabajo intentamos resumir la evidencia, para determinar si la asistencia artroscópica aporta beneficios adicionales para evitar incongruencias articulares en comparación con los resultados obtenidos bajo asistencia fluoroscópica. Material y métodos: Búsqueda sistemática de estudios prospectivos, retrospectivos, de cohortes, seguimiento, ensayos clínicos en PubMed, MEDLINE, Scopus, Scielo, Embase, Google Scholar y otras fuentes nacionales, incluyendo como palabras clave los términos: intraarticular distal radius fracture, wrist arthroscopy, arthroscopy, fluoroscopy. Los valores medios y desvíos estándar para cada característica, obtenidos de los trabajos seleccionados fueron analizados usando estadística descriptiva y gráficos ilustrativos. Resultados: Fueron evaluados 463 pacientes (256 mujeres y 207 hombres), con una edad promedio de 48.29 años y rango de 39 a 64 años. Los dos tratamientos (A y F) fueron homogéneos en cuanto a la edad de los pacientes que reportan (p = 0.5820) y el tiempo de seguimiento promedio (p = 0.9597). Sólo la desviación cubital y el DASH, para las cuales el grupo de artroscopía tuvo mejor desempeño, en las variables restantes las diferencias no fueron significativas. Conclusión: La evidencia disponible hasta la fecha es controvertida y no permite hacer recomendaciones a favor o en contra de estas intervenciones, encontrando otros factores que podrían influir en la toma de decisiones.

Abstract: Introduction: Intraarticular distal radius fractures are a therapeutic challenge for the orthopedist surgeon there are studies that support the use of fluoroscopy, and others promote arthroscopy, with this work we try to summarize the evidence, to determine whether arthroscopic assistance provides additional benefits to avoid joint incongruities compared to results obtained under fluoroscopic assistance. Material and methods: Systematic search for prospective, retrospective, cohort, follow-up, clinical trials on PubMed, MEDLINE, Scopus, Scielo, Embase, Google Scholar and other national sources, including as keywords the terms: «intra-articular distal radius fracture¼, «wrist arthroscopy¼, «arthroscopy¼, «fluoroscopy¼. The average values and standard offsets for each characteristic, obtained from the selected works, were analyzed using descriptive statistics and illustrative graphs. Results: 463 patients (256 women and 207 men) were evaluated, with an average age of 48.29 years and range from 39 to 64 years. The two treatments (A and F) were homogeneous in terms of the age of the patients reporting (p = 0.5820) and the average follow-up time (p = 0.9597). Only the ulnar deviation and DASH score, for which the arthroscopy group performed best, in the remaining variables the differences were not significant. Conclusion: The evidence available to date is conflicting, and does not allow recommendations to be made for or against these interventions, finding other factors that could influence decision-making.

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The association of ipsilateral talar and calcaneal fractures is an uncommon combination and is typically the result of a high-energy trauma. It is often associated with comminution, marked fracture displacement, and soft-tissue compromise. Obtaining satisfactory clinical and radiographic results is very challenging. Residual deformities, multiple procedures, and limitations are usually the norm. Therefore, studies have suggested that primary arthrodesis may represent the best option of surgical treatment. In this study, we report a case of a 30-year-old male patient with a rare combination of a highly comminuted transcalcaneal fracture-dislocation associated with a talar neck fracture successfully treated with open reduction and internal fixation (ORIF) with an 18-month follow-up. This case demonstrates that even when there are associated fractures of the talus and calcaneus with severe bone loss, ORIF may provide satisfactory outcomes in the short-term postoperative period.Levels of Evidence: Level V: Case report.

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