Cases reported "Tibial Fractures"

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1/124. Lessons to be learned: a case study approach diuretic therapy and a laxative causing electrolyte and water imbalance, loss of attention, a fall and subsequent fractures of the tibia and fibula in an elderly lady.

    The case is described of a hitherto well, alert and intelligent lady of 85 years of age, who commenced medication with diuretics--prescribed for mild congestive cardiac failure; she developed constipation consequent upon the diuresis and dehydration thereby provoked. As a result she began to take, unknown to her general practitioner, regular and increasing amounts of laxatives. At about this time she was noted by her son to become "rapidly senile"--with the result that she fell on account of losing her normally good concentration and attention; she sustained fractures of the right tibia and fibula. Shortly after admission to hospital she was premedicated, anaesthetised and operated upon, following which there was a postoperative regimen comprising several litres of low sodium isotonic infusions, all given intravenously. She was found at this point to be severely hyponatraemic with a low serum osmolality, but following the institution of water restriction rapidly improved as her serum sodium rose again; there was an accompanying massive diuresis as the previously retained water was voided. Concomitant with the serum sodium rise her mental concentration and attention regained their former levels. The biochemical and cellular mechanisms underlying this patient's symptoms are discussed.
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2/124. Heat-induced segmental necrosis after reaming of one humeral and two tibial fractures with a narrow medullary canal.

    In three cases referred to our clinic (a simple fracture of the humeral shaft, a simple, closed fracture, and a wedge fracture of the mid-third of the tibia), bone necrosis had resulted from excessive heat produced by reaming extremely narrow medullary cavities (5-5.5 mm diameter) with the 9 mm front-cutting reamer as part of a reamed nailing procedure. In any one case, different degrees of damage can occur from the metaphysis to the diaphysis. Based on the clinical course and the histological evaluation, we postulate that heat-induced damage can be divided into four degrees of severity (0-3): Grade 0: no damage; no devascularization, no heat-induced damage. Grade 1: The heat damaged zone is cut away during subsequent reaming, the only damage is devascularization. Grade 2: The damaged zones are not eliminated by subsequent reaming. The bone is devascularized and heat damaged. Grade 3: The entire cross section of the bone including the periosteum is devitalized by exposure to excessive heat. Depending on the severity of additional damage to the soft tissues, grave consequences are to be expected and further operations are unavoidable. The effects of heat-induced damage are particularly critical in the presence of infection (cases 2 and 3). The fundamental aspects and the extent of heat necrosis will be discussed. After discussion with the AO Technical Commission on the cause of heat-induced necrosis, we would recommend the following preventive measures: 1. preoperative measurement of the smallest diameter of the medullary cavity in two planes. 2. reaming with the standard instrumentation (9 mm) only if the medullary cavity has a diameter of at least 8 mm at its narrowest point. 3. Extremely narrow cavities should first be reamed manually or an alternative to nailing should be sought. 4. It is strongly recommended that only sharp reamers be used in such cases and blunt or damaged reamers replaced.
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3/124. Nonunion of tibial stress fractures in patients with deformed arthritic knees. Treatment using modular total knee arthroplasty.

    In two years we treated four women with ununited stress fractures of their proximal tibial diaphyses. They all had arthritis and valgus deformity. The stress fractures had been treated elsewhere by non-operative means in three patients and by open reduction and internal fixation in one, but had failed to unite. After treatment with a modular total knee prosthesis with a long tibial stem extension, all the fractures united. A modular total knee prosthesis is suitable for the rare and difficult problem of ununited tibial stress fractures in patients with deformed arthritic knees since it corrects the deformity and the adverse biomechanics at the fracture site, stabilises the fracture and treats the arthritis.
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4/124. Transcranial doppler detection of fat emboli.

    BACKGROUND AND PURPOSE: The fat embolism syndrome (FES) is characterized by the simultaneous occurrence of pulmonary and neurological symptoms as well as skin and mucosal petechiae in the setting of long-bone fractures or their surgical repair. Its pathophysiology is poorly understood, and effective treatments are lacking. We present 5 patients with long-bone fractures in whom in vivo microembolism was detected by transcranial Doppler. methods: Five patients with long-bone fractures were monitored with transcranial Doppler for microembolic signals (MESs) after trauma. Two patients also had intraoperative monitoring. A TC-2020 instrument equipped with MES detection software was used. Detected signals were saved for subsequent review. Selected signals satisfied criteria defined previously and were categorized as large or small. RESULTS: Cerebral microembolism was detected in all 5 patients and was transient, resolving within 4 days of injury. Intraoperative monitoring revealed an increase in MESs during intramedullary nail insertion. The characteristics of MESs after injury varied among patients, with large signals being more frequent in the only patient with a patent foramen ovale. CONCLUSIONS: Cerebral microembolism after long-bone fractures can be detected in vivo and monitored over time. These findings may have potential diagnostic and therapeutic implications.
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ranking = 2
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5/124. Combined talar body and tibial plafond fracture: a case report.

    We report a case of a crush fracture of the body of the talus associated with an anterior tibial plafond fracture. This injury is a rare variant of talar body fracture which merits special attention. The bony injury in this type of fracture is associated with multiple loose fragments involving both weightbearing surfaces of the ankle joint. After appropriate imaging to allow preoperative planning, we utilized a two-incision approach which was necessary to achieve adequate exposure and fixation. We used basic fracture management principles to deal with a previously undocumented fracture pattern.
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6/124. Intraoperative imaging of the tibial plafond fracture: a potential pitfall.

    STUDY DESIGN: Human tibial plafond cadaveric specimens were coronally sectioned and imaged to assess the accuracy of evaluation of ankle joint line congruity using anteroposterior radiography. Two interesting representative clinical cases are discussed. OBJECTIVES: To evaluate the validity of the routine use of anteroposterior radiographs to evaluate intra-operative ankle joint line congruity in circumstances where lateral radiographs are infeasible due to obscuring internal or external hardware. methods: Eleven frozen human cadaveric lower extremity specimens were used in this study. At the level of the tibial plafond, the specimens were sequentially sliced into 0.5cm sections in the coronal plane. True anteroposterior radiographs were taken with the specimen en bloc. Sequentially, the posterior slices were removed one by one, with an image taken after removing each section. The process was then repeated by removing the anterior sections sequentially with intervening radiographs. Each series of anteroposterior radiographs was then evaluated to characterize which portion of the joint line on the whole specimen view had been contributed by each of the sections. This then allowed us to make inferences about the evaluation of the joint line if it had been derived solely by anteroposterior radiography. Two poignant clinical cases demonstrating the clinical relevance of this information are discussed. RESULTS: By sequentially imaging after removing coronal sections of the tibial plafond we were able to accurately characterize the contribution of each portion of the plafond to the overall anteroposterior view. By primarily imaging the anterior portions of the plafond, with the posterior portions removed, the joint line image was virtually unchanged from the en bloc anteroposterior radiograph. However, removal of the anterior coronal sections caused large variation in the joint line image. These observations demonstrate that the anteroposterior radiograph of the tibial plafond characterizes the anterior portion of the joint well, while it represents a poor assessment of the posterior portion of the joint. This was well illustrated in our clinical case presentations. CONCLUSION: In severe fractures of the tibial plafond multiple forms of internal and external devices are frequently used for fixation. In these circumstances hardware may obscure the lateral view making it impossible to obtain adequate lateral radiographs to assess fracture reduction and joint line congruity. In this scenario, the anteroposterior radiograph is frequently relied upon to confirm the anatomic relationship of the displaced fragments. However, this view fails to accurately characterize reduction in the entire joint line and, intra-operatively, may mislead the surgeon to accept a reduction as anatomic when intra-articular incongruity still exists. Strict attention to pre-operative radiographs and the use of additional rotated views may aid the surgeon in this setting to assess fracture reduction and joint line congruence.
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ranking = 7
keywords = operative
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7/124. Immediate tibiocalcaneal arthrodesis with interposition fibular autograft for salvage after talus fracture: a case report.

    Treatment goals in the operative management of talus fractures include prompt, anatomic, open reduction with rigid internal fixation; functional outcome is measured by degree of arthrosis, pain, range of motion, limb length, cosmesis, and return to premorbid activities. If restoration of the articular surfaces is precluded secondary to comminution, immediate and/or staged reconstructive salvage procedures must be considered. This report describes an immediate reconstructive procedure for salvage after a comminuted talus fracture with an ipsilateral tibia fracture. A standard antegrade tibial nail extending into the calcaneus was selected to stabilize both fracture sites. The technique of tibiocalcaneal arthrodesis using interposition fibular autograft and intramedullary fixation is presented as a unique treatment option.
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8/124. 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.
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9/124. Treatment of infection and non-union after bilateral complicated proximal tibial fracture.

    BACKGROUND AND AIMS: Complicated tibial fractures form a great challenge for orthopaedic surgeons. Non-unions and infections are more common in complicated than in closed fractures. In the present study, we describe a patient case treated for non-union combined to chronic osteomyelitis after bilateral open proximal tibial fractures. MATERIAL AND methods: A female patient born in 1946 was multi-traumatised, when a car hit her as a pedestrian. She went through multiple operations of both tibias due to bilateral complicated proximal fractures. Fractures were stabilised at first with internal fixation, which had to be changed to external fixation due to infection of both sides. During the last operative step a commercial bone graft based on hydroxyapatite and bovine type I fibrillar collagen/tricalcium phosphate ceramic (Collagraft) mixed with autogenous bone marrow was applied. RESULTS: Fractures united after 28 (right tibia) and 22 (left tibia) months of follow-up. At the final follow-up visit 55 months after the initial accident patient walked without any aid and showed no signs of an infection. CONCLUSIONS: The use of commercial mixed xeno-/autogenous-bone graft may provide a feasible alternative in complicated chronic non-unions of the tibia even when an infection is present, especially when autogenous bone is not easily available after previous attempts of bone grafting.
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10/124. Percutaneous plating of the low energy unstable tibial plateau fractures: a new technique.

    We discuss the management of two low-energy unstable tibial plateau fractures in this report, and describe our new technique of percutaneous plating to stabilise these fractures. This minimally invasive surgery has the obvious advantages to the traditional open reduction and internal fixation and the non-operative management by plaster immobilisation. Stable fixation can be achieved by small fragment plates used in this technique allowing safe mobilisation. This novel method of internal fixation could be a useful inclusion in the armamentarium for the management of tibial plateau fractures and can be safely practised by an orthopaedic surgeon at a District General Hospital.
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