Cases reported "Bone Malalignment"

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1/10. Salvage of contaminated fractures of the distal humerus with thin wire external fixation.

    Fractures and osteotomies of the distal humerus that are contaminated or infected represent a difficult management problem. Stable anatomic fixation with plates and screws, the acknowledged key to a good result in the treatment of bicondylar fractures, may be unwise. A thin wire circular (Ilizarov) external fixator was used as salvage treatment in such complex situations in five patients. The fixator allowed functional mobilization of the elbow while allowing achievement of the primary goal of eradicating the infection or colonization. Two patients required a second operation for fixation of a fibrous union of the lateral condyle. One patient with a vascularized fibular graft later required triple plate fixation for malalignment at the distal host and graft junction. Four of five patients ultimately achieved complete union. The fracture remained ununited in one patient who has declined additional intervention. All five patients achieved at least 85 degrees ulnohumeral motion, two after a secondary elbow capsulectomy performed after healing was achieved. This experience suggested that the Ilizarov construct, although not a panacea, represents a reliable method of skeletal stabilization that allows functional mobilization while elimination of infection or colonization is ensured. If necessary, stiffness and incomplete healing can be addressed with an increased margin of safety at subsequent operations.
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2/10. Fracture of the proximal tibia six months after Fulkerson osteotomy. A report of two cases.

    The Fulkerson osteotomy has proved to be a reliable treatment for subluxation of the patella due to malalignment. Aggressive rehabilitation in the early postoperative period is unwise since the proximal tibia is weakened by the oblique osteotomy. Early weight-bearing and unrestricted activity have caused fractures in a few patients. Even late in the postoperative period the osteotomy may adversely influence the biomechanical properties of the proximal tibia. We describe two athletes who sustained a fracture of the proximal tibia, during recreational activities, six months after a Fulkerson osteotomy. Both had been bearing full weight for about ten weeks without complaint. Bony healing of the osteotomy had been demonstrated on plain radiographs at ten and at 12 weeks. After a Fulkerson osteotomy, jogging and activities which impose considerable impact force should be discouraged for at least nine to 12 months.
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3/10. Malrotation after locked intramedullary tibial nailing: three case reports and review of the literature.

    BACKGROUND: Malrotation after interlocked tibial nailing is rarely documented. methods: We report the cases of three patients who incurred symptomatic rotational deformities after closed intramedullary nailing for low-energy spiral fractures of the distal third of the tibia. RESULTS: Two patients elected surgical correction, with excellent clinical results. CONCLUSION: Malrotation may cause functional deficits, but the long-term consequences of rotational deformities in the tibia have not been thoroughly studied. Malrotation after tibial nailing is probably more common than reported. Intraoperative comparison with the uninjured leg may be the best means available for avoiding this postoperative complication.
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keywords = fracture
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4/10. Coronal fractures of the proximal scaphoid: the proximal ring sign.

    We present two coronal fractures of the proximal scaphoid which were both missed in the acute stage as interpretation of initial radiographs was difficult. In both cases, recognition of the so-called "Proximal Ring Sign" on the PA ulnar deviation radiographs may have helped diagnosis. CT scans were necessary to fully demonstrate the fractures. Open reduction and internal fixation, performed 2 and 4 months after the injury, resulted in union in both cases.
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5/10. Osteoporotic vertebral fracture adjacent to a nonsegmented hemivertebra.

    A combination of osteoporotic vertebral fractures and congenital spinal deformity is theoretically possible, but there have been no reports on this combination in the literature. We describe a rare case of an osteoporotic vertebral fracture adjacent to the nonsegmented hemivertebra. A 60-year-old postmenopausal woman who did not recall any specific trauma presented with severe back pain. She had markedly decreased bone mineral density and significant lumbar kyphoscoliosis with a nonsegmented hemivertebra between L1 and L2 on radiographs of the lumbar spine. magnetic resonance imaging (MRI) revealed a vertebral fracture adjacent to the nonsegmented hemivertebra. Laboratory studies showed increased serum bone-specific alkaline phosphatase (BAP) and urinary type I collagen crosslinked N-telopeptide (NTx). A thoracolumbar brace was applied for 3 months. Daily administration of alendronate normalized her serum BAP and urinary NTx levels. MRI scans of the lumbar spine after 6 months also confirmed normalized signal intensities of the fractured vertebra adjacent to the nonsegmented hemivertebra. The vertebral fracture seemed to be induced by spinal malalignment, increased stress on the adjacent level of the fused segment, and its fragility due to osteoporosis.
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6/10. Stress fracture of the femoral neck as a complication of total knee arthroplasty.

    Stress fracture of the hip is a rare complication of total knee arthroplasty that occurs most often in patients in whom a significant deformity of the knee has been corrected, particularly those with poor mobility before surgery. We report 4 cases of ipsilateral fracture of the femoral neck after total knee arthroplasty.
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7/10. Case report: Radial overgrowth and deformity after metaphyseal fracture fixation in a child.

    Pediatric fractures sometimes are complicated by growth disturbances. Most reported growth disturbances are in the lower extremity and can entail growth arrest or overgrowth. We report a case of overgrowth and angular deformity after an extraphyseal distal radius fracture that resulted in clinically significant pain and functional impairment because of palmar instability of the distal ulna. A dome osteotomy was successful in treating the patient's wrist pain, distal radioulnar instability, and multiplanar deformity of the distal radius.
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8/10. Perforation of the small intestine caused by fixation plate penetration into the abdomen.

    The authors report a case of intestinal loop penetration and peritonitis caused by penetration of the tip of the fixation into the abdominal cavity after internal fixation of an unstable intertrochanteric fracture. Complete regression of acute infection was achieved by suturing the intestinal wound, removing the internal fixation device and administering systemic and local antibiotic therapy.
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9/10. Impending malunions of the hand. Treatment of subacute, malaligned fractures.

    Malunions of the hand present a challenging problem to the orthopaedic surgeon. Angular and rotational deformities, and shortening and articular incongruity, can lead to significant functional impairment or dysesthetic appearance. The prevention of malunion should remain a primary goal. When displaced fractures of the metacarpals or phalanges present within the first or second weeks, properly performed closed or open reduction with percutaneous pinning or internal fixation are excellent options with predictable results. Malaligned fractures that present later frequently cannot be readily reduced. Once fully united, treatment options have included corrective osteotomy if function is significantly impaired or if appearance is objectionable; for patients who are not suitable for surgery for medical or other reasons, or for whom appearance is acceptable, intensive occupational therapy to maximize function may yield sufficiently serviceable clinical results. During the past several years, the senior author (BL) has chosen to be more proactive in the prevention of malunions of the hand. In the authors' experience, results of aggressive surgical treatment of subacute, malaligned fractures in selected patients have produced results comparable with or superior to those reported for later reconstructive procedures. With the proliferation of managed care, there has been an increasing frequency of delayed referral patterns for fracture treatment by hand specialists. Definitive treatment of these "impending malunions" is preferable to passive treatment delay and secondary reconstructive procedures, offering both earlier correction of alignment and earlier opportunity for return of function.
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10/10. Significance of corrective growth of opposite physes in the surgical correction of deformity following epiphyseal injury around the knee joint.

    Deformation due to growth disturbance after epiphyseal fractures around the knee may involve more than the primarily injured epiphysis, as spontaneous corrective growth of the opposite epiphyseal plate can take place in an attempt to maintain overall alignment of the leg. As a result, there will be an inclination in the knee joint line if corrective osteotomy is only performed for the primary angulation. We report two cases of this complex deformity in which corrective osteotomies of both the distal femur and the proximal tibia were performed, resulting in correct alignment of the overall leg axis and knee joint axis.
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