Acute syndesmotic injuries in ankle fractures:From diagnosis to treatment and current concepts

A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship,and it is essential for normal motion of the ankle joint.The disruption of this joint is frequently accompanied by rotational ankle fracture,such as pronation-external rotation,and rarely occurs without ankle fracture.The diagnosis is not simple,and ideal management of the various presentations of syndesmotic injury remains controversial to this day.Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes.In such an injury,including inadequately treated,misdiagnosed and correctly diagnosed cases,a chronic pattern characterized by persistent ankle pain,function disability and early osteoarthritis can result.This paper reviews anatomical and biomechanical characteristics of this syndesmosis,the mechanism of its acute injury associated to fractures,radiological and arthroscopic diagnosis and surgical treatment.

Ankle Arthroscopy: A Complimentary Adjunct in the Diagnosis and Management of Ankle Fractures

Ankle fractures are one of the most common injuries treated by orthopaedic surgeons. A minority of patients with ankle fractures go on to develop persistent pain following anatomical reduction. These sequelae may arise as a result of untreated ligamentous or chondral injuries. This study aims to correlate acute arthroscopic ankle findings with the Lauge-Hansen fracture pattern classification. We further aim to compare subjective functional outcomes at least one year following surgery between patients who have received Open Reduction and Internal Fixation (ORIF) alone, versus ORIF plus arthroscopy. This is a retrospective case series of patients who have undergone ankle fracture ORIF +/- arthroscopy from July 2014 to July 2017 inclusive. Each patient’s presenting radiograph was classified according to the Lauge-Hansen ankle fracture classification with subsequent correlation to intra-operative arthroscopic findings. Functional outcome at a minimum of one year was evaluated with the American Academy of Orthopaedic Surgeons (AAOS) metric. Twenty two patients underwent ankle ORIF plus arthroscopy (Group A) with a further 26 patients receiving ORIF alone (Group B). 1 in 3 supination-external-rotation type II (SER II) injuries possessed a concomitant syndesmosis injury or osteochondral lesion (OCL) on arthroscopy. 1 in 3 patients with an SER IV injury had an osteochondral lesion. The mean AAOS score achieved for Group A was 89.6 (±7.9) with the mean score for Group B being 82.0 (±13.7). In conclusion, ankle arthroscopy aids the diagnosis and treatment of ligamentous and osteochondral injuries not evident on plain film with subsequent superior short-term outcomes.

Functional assessment and influencing factors after staged functional training in patients with ankle fractures

BACKGROUND The recovery of limb function after ankle fracture surgery is a gradual process.The main purpose of implementing early functional exercise,joint mobility,muscle contraction function,passive ankle flexion and extension exercises,or physical factor therapy techniques is to achieve the rapid recovery of normal physiological limb function.However,currently the most effective rehabilitation training method is staged limb functional exercise,which promotes rapid recovery of limb function while preventing adverse consequences caused by overwork or insufficient training.Staged limb functional exercise divides the rehabilitation process into multiple stages,each of which has specific training objectives and contents.This method helps patients gradually restore limb function.Nevertheless,some patients still exhibit poor limb function after standardized exercise.Therefore,a functional evaluation should be performed to analyze the impact of staged functional training after ankle fracture surgery.AIM To perform a functional evaluation and determine the influencing factors of staged functional training in patients with ankle fracture.METHODS A retrospective study enrolled 150 patients who underwent surgical treatment for ankle fracture from May 2020 to May 2022 at our hospital.Univariate and multivariate linear regression analyses were performed on general data,functional exercise compliance scale for orthopedic patients,Social Support Rating Scale(SSRS),American Orthopedic Foot and Ankle Score(AOFAS)Ankle-Hindfoot Score,and pain factors[serum bradykinin(BK),prostaglandin E2(PGE2),5-hydroxytryptamine(5-HT)].RESULTS Based on the AOFAS Ankle-Hindfoot Scale,the cases were divided into the excellent function(n=111)and ordinary function(n=39)groups.Univariate analysis revealed that monthly family income,education level,diabetes mellitus,functional exercise compliance scale of orthopedic patients score,SSRS,BK,PGE2,and 5-HT significantly influenced limb function after ankle fracture(P<0.05);Multiple linear regression analysis showed that the functional exercise compliance scale score,SSRS,BK,PGE2,and 5-HT were independent risk factors affecting functional performance after staged functional exercise(P<0.05).CONCLUSION Exercise compliance,SSRS,and pain level are the independent risk factors affecting functional performance after staged functional training following ankle surgery.Clinical nursing care after ankle surgery should include analgesic and health education measures to ensure optimal recovery of limb function.

Diagnosing syndesmotic instability in ankle fractures

The precise diagnosis of distal tibiofibular syndesmotic ligament injury is challenging and a distinction should be made between syndesmotic ligament disruption and real syndesmotic instability.This article summarizes the available evidence in the light of the author’s opinion.Pre-operative radiographic assessment,standard radiographs,computed tomography scanning and magnetic resonance imaging are of limited value in detecting syndesmotic instability in acute ankle fractures but can be helpful in planning.Intra-operative stress testing,in the sagittal,coronal or exorotation direction,is more reliable in the diagnosis of syndesmotic instability of rotational ankle fractures.The Hook or Cotton test is more reliable than the exorotation stress test.The lateral view is more reliable than the AP mortise view because of the larger displacement in this direction.When the Hook test is used the force should be applied in the sagittal direction.A force of 100 N applied to the fibula seems to be appropriate.In the case of an unstable joint requiring syndesmotic stabilisation,the tibiofibular clear space would exceed 5 mm on the lateral stress test.When the surgeon is able to perform an ankle arthroscopy this technique is useful to detect syndesmotic injury and can guide anatomic reduction of the syndesmosis.Many guidelines formulated in this article are based on biomechanical and cadaveric studies and clinical correlation has to be established.

Ankle Fractures: A Literature Review of Current Treatment Methods

Ankle fracture is one of the most common lower limb fractures for they account for 9% of all fractures representing a significant portion of the trauma workload. Ankle fractures usually affect young men and older women, however, below the age of 50;ankle fractures are the commonest in men. Two commonly used classification systems for ankle fractures include the danis weber AO classification and the Lauge-Hansen classification. There is biomechanical evidence that posterior non-locking plates are superior in stability than laterally placed plates;however there is little clinical evidence. There are several different methods of ankle fracture fixation, however the goal of treatment remains a stable anatomic reduction of talus in the ankle mortise and correction of the fibula length as a 1 mm lateral shift of the talus in the ankle mortise reduces the contact area by 42%, and displacement (or shortening) of the fibula more than 2 mm will lead to significant increases in joint contact pressures. Further research both biomechanically and clinically needs to be undertaken in order to clarify a preferable choice of fixation.

IMAGING DIAGNOSIS OF THORACOLUMBAR BURST FRACTURES

Objective To review imaging use in the diagnosis of thoracolumbar burst fractures and to determine the diagnostic va-lue of different imaging methods. Methods One hundred and fourteen patients with 120 thoracolumbar burst fractures were retrospectively reviewed. Pl-ain radiographs were available in all cases; CT scans and MRI were obtained in 96 and 74 cases, respectively. Results A total of 27 burst fractures were misdiagnosed as other types of fractures on radiographs alone, and accounted for 22.5% of all fractures. The results indicated that plain radiographs often fail to delineate the pathological features of thor-acolumbar burst fractures, leading to delay in diagnosis. Conclusion In regard to thoracolumbar injury diagnosis, burst fractures should be differentiated from compression frac-tures. CT should be routinely indicated and MRI examination, when necessary, may be simultaneously considered.

Update on diagnosis and management of cuboid fractures

Cuboid fractures due to the particular bone anatomy and its protected location in the midfoot are rare, and they are usually associated with complex injuries of the foot. Clinical examination to diagnose these fractures should be detailed and the differential diagnosis, especially in the case of vague symptoms, should include the exclusion of all lateral foot pain causes. Conventional radiographs do not always reveal occult fractures, which can be under diagnosed especially in children. In this case, further investigation including magnetic resonance imaging or scintigraphy may be required. The treatment of these injuries depends on the particular fracture characteristics. Non-displaced isolated fractures of the cuboid bone can be effectively treated conservatively by immobilization and by avoiding weight bearing on the injured leg. In the case of shortening of the lateral column> 3 mm or articular displacement > 1 mm, surgical management of the fracture is mandatory in order to avoid negative biomechanical and functional consequences for the foot and adverse effects such as arthritis and stiffness as well as painful gait. In this review, an update on diagnosis and management of cuboid fractures is presented.

Ultrasound diagnosis of fractures in mass casualty incidents

The role of point-of-care ultrasound in mass casualty incidents(MCIs)is still evolving.Occasionally,hospitals can be destroyed by disasters resulting in large number of trauma patients.CAVEAT and FASTER ultrasound protocols,which are used in MCIs,included extremity ultrasound examination as part of them.The literature supports the use of ultrasound in diagnosing extremity fractures both in hospitals and MCIs.The most recent systematic review which was reported by Douma-den Hamer et al in 2016 showed that the pooled ultrasound sensitivity and specificity for detecting distal forearm fractures was 97% and 95% respectively.Nevertheless,majority of these studies were in children and they had very high heterogeneity.The portability,safety,repeatability,and cost-effectiveness of ultrasound are great advantages when treating multiply injured patients in MCIs.Its potential in managing fractures in MCIs needs to be further defined.The operator should master the technique,understand its limitations,and most importantly correlate the sonographic findings with the clinical ones to be useful.This editorial critically reviews the literature on this topic,describes its principles and techniques,and includes the author’s personal learned lessons so that trauma surgeons will be encouraged to use ultrasound to diagnose fractures in their own clinical practice.

Diagnosis and Treatment and Infection Protection Strategy of Osteoporotic Vertebral Compression Fractures Minimally Invasive Percutaneous Kyphoplasty Surgery during the Prevention and Control of COVID-19

Background: As the global novel coronavirus pneumonia (NCP) remains severe, elderly people are at high risk for NCP and osteoporotic vertebral compression fractures, with high complications and mortality. How to treat patients and protect medical staff from infection, and at the same time strictly prevent the occurrence of clustered transmission events in the hospital, the establishment of perfect pre-hospital emergency measures and infection prevention and control strategy is the first element to ensure success. Objective: To establish the diagnosis and treatment and infection protection strategy for Osteoporotic vertebral compression fractures (OVCF) patients undergoing minimally invasive percutaneous kyphoplasty (PKP) surgery during the prevention and control of COVID-19, so as to ensure the stable, orderly and safe medical treatment. Methods: A total of 583 OVCF patients were admitted to the First Affiliated Hospital of Hebei North University during the epidemic prevention and control period from January 2020 to July 2022. After urgent and outpatient strict standardized screening, 382 patients met the inclusion criteria, including 112 males and 270 females, aged (70.50 ± 5.49) years. The preoperative visual analogue scale (VAS) score was 6.92 ± 1.86. Preoperative Oswestry disability index (ODI) was 74.67 ± 4.84. The satisfaction rate was (45.89 ± 3.67) %. According to the clinical diagnostic criteria and classification, 367 patients were diagnosed as ordinary OVCF, including 156 cases of mild compression and 226 cases of moderate compression. The clinical classification of 15 patients with OVCF diagnosed as COVID-19 was type I, including 10 cases of mild COVID-19 and 5 cases of common COVID-19. All patients were treated with PKP. Results: All patients were followed up at 1 day, 1 month and 3 months after operation, VAS (2.01 ± 0.56, 0.45 ± 0.11, 0 ± 0), ODI (45.41 ± 4.15, 10.22 ± 2.73, 4.03 ± 1.57) and satisfaction (90.12%, 95.57%, 99.23%) were significantly improved compared with those before operation (p < 0.05), and the original medical diseases were not aggravated. In this group, 15 cases of OVCF diagnosed with COVID-19 were given priority to treat COVID-19 under strict three-level protection in the designated isolation ward. PKP was carried out after the condition was stable, and the areas, items and personnel in contact with patients during the perioperative period must be strictly and thoroughly disinfected. The patient had a good prognosis, no complications, no cross-infection in the hospital, and no infection rate among medical staff. Conclusions: The implementation of the diagnosis and treatment and infection protection strategy for OVCF patients undergoing minimally invasive PKP surgery during the prevention and control of COVID-19 has a guiding role in preventing the spread of infection, improving the cure rate, promoting rapid recovery, reducing complications and reducing mortality.

Ankle Arthrodesis Nail Combined with Locking Compression Plate to Stabilize Two-Level Pathologic Tibial Fractures

Treatment of fragility fractures of the distal tibia in the elderly is demanding because of osteopenic bone quality, the delicate soft tissue cuff and frequent critical circulation. We report the case of two-level tibial pseudarthroses in an 83- year-old woman caused by multiple myeloma successfully stabilized by a long ankle arthrodesis nail combined with locking compression plate osteosynthesis. This case is unique, as to our best knowledge, herein diaphyseal fractures were treated for the first time using a technique reported hitherto primarily for fragility ankle and pilon fractures.

Ankle Arthrodesis in the Treatment of Neglected Ankle Fractures

Introduction: Neglected ankle fractures are common in our regions. Patients first consult traditional healers and it is when the signs persist that they consult the surgeon for a swollen and painful ankle. Initially we always performed anatomical repairs with osteosynthesis, but the majority of patients still complained of pain and disability. We wondered whether a primary arthrodesis would not be indicated in old ankle fractures to avoid disabling pain for patients. We therefore performed a series of arthrodesis on neglected post-traumatic ankles. The objective of our study was to describe the results of arthrodesis on an old post-traumatic ankle and to propose a therapeutic indication in the face of any neglected ankle fracture. Material and Method: This was a prospective study over 8 years between December 2012 and November 2020, involving 36 cases of neglected ankle fractures treated by arthrodesis using Meary’s technique. We used AOFAS (American Orthopedic Foot and Ankle Score) preoperatively and postoperatively for an objective assessment. Results: The average follow-up was 4.2 years and our results were satisfactory (94.4%) with an average AOFAS score ranging from 27.8 preoperatively to 76.7 postoperatively. The fusion rate was 97.2%. Discussion: Arthrodesis appears here as an important alternative in the treatment of neglected ankle fractures with significant trophic disorders.

Ankle Fractures, Short Term Operative Outcome: A Retrospective Case Series

Introduction and Background: Ankle injury is one of the most frequent presenting injuries to the emergency room and ankle fractures are common fracture in the lower limbs injuries that may require operative treatment with variable outcomes. Materials and Methods: Sixty-three patients were included in my retrospective study, and all with a displaced fracture of the ankle caused by high energy trauma were treated by open reduction and rigid internal fixation. Results: After follow-up at six weeks and twelve weeks, the results were satisfactory in fifty-five percent out of all the sixty-three patients. Conclusions and Recommendations: Ankle fractures occur mainly in young males of the age group between 26 and 35 years, mostly caused by fall down and motor vehicle accident.

Application of computer aided 3D simulation technique for complicated foot and ankle fractures

Objective To investigate the effect of computer aided 3D simulation technique for treating complicated foot and ankle fractures precisely.Methods From November 2007 to August 2009,255 patients with complicated foot and ankle fractures

Ankle fracture configuration following treatment with and without arthroscopic-assisted reduction and fixation

AIM: To report ankle fracture configurations and bone quality following arthroscopic-assisted reduction and internal-fixation(ARIF) or open reduction and internalfixation(ORIF). METHODS: The patients of ARIF(n = 16) or ORIF(n = 29) to treat unstable ankle fracture between 2006 and 2014 were reviewed retrospectively. Baseline data, including age, sex, type of injury, immediate postoperative fracture configuration(assessed on X-rays and graded by widest gap and largest step-off of any intraarticular site), bone quality [assessed with bone mineral density(BMD) testing] and arthritic changes on X-rays following surgical treatments were recorded for each group.RESULTS: Immediate-postoperative fracture configurations did not differ significantly between the ARIF and ORIF groups. There were anatomic alignments as 8(50%) and 8(27.6%) patients in ARIF and ORIF groups(P = 0.539) respectively. There were acceptable alignments as 12(75%) and 17(58.6%) patients in ARIF and ORIF groups(P = 0.341) respectively. The arthritic changes in follow-up period as at least 16 wk following the surgeries were shown as 6(75%) and 10(83.3%) patients in ARIF and ORIF groups(P = 0.300) respectively. Significantly more BMD tests were performed in patients aged > 60 years(P < 0.001), ARIF patients(P = 0.021), and female patients(P = 0.029). There was no significant difference in BMD test t scores between the two groups. CONCLUSION: Ankle fracture configurations following surgeries are similar between ARIF and ORIF groups, suggesting that ARIF is not superior to ORIF in treatment of unstable ankle fractures.

Understanding Osteoporosis: Pathophysiology, Risk Factors, Diagnosis, and Management

Osteoporosis is a systemic skeletal disease characterized by low bone mineral density (BMD) and deterioration of bone architecture, resulting in reduced bone strength and, consequently, increased susceptibility to fractures which poses a significant public health concern worldwide, particularly in aging populations [1]. The health-economic impact of vertebral and hip fractures has been extensively explored and it is well known that these fractures are associated with morbidity/disability and increased mortality;they also account for a substantial portion of the direct fracture costs. This review aims to provide a comprehensive overview of osteoporosis, including its pathophysiology, risk factors, diagnostic approaches, and management strategies. By elucidating the multifaceted nature of this condition, healthcare providers can better identify individuals at risk, implement preventive measures, and optimize treatment to reduce the burden of osteoporotic fractures.

Lateral femoral neck stress fractures: A case report

BACKGROUND Sport-induced injuries particularly affect young,healthy,and active individuals.Running,a popular and accessible sport,can cause a wide range of injuries,including stress fractures.Stress fractures can occur during high-intensity training or competitions,especially among well-trained amateurs and professional athletes.Adequate diagnosis can be complicated by the typically young age,unremarkable medical history,and vital condition of the patient.Stress fractures present insidiously,and this is specifically the case with stress fractures of the femoral neck.Timely intervention is crucial to prevent progressive displacement,as this can damage the blood supply to the femoral head.CASE SUMMARY A 30-year-old male runner presented to our outpatient clinic with persistent pain 3 weeks after running a marathon.X-ray showed a complete lateral fracture of the left femoral neck,which was treated surgically with a dynamic hip screw.CONCLUSION It is essential for healthcare providers to be vigilant for the subtle symptoms of stress fractures to ensure timely treatment.Early recognition prevents com-plication and leads to a better prognosis.

Diagnosis and Treatment of a Case of Radius and Ulna Fracture in Dog

60% of a dog's body weight is supported by its fore limbs, while the hind limbs mainly play the role of power, so the probability of dog's radius and ulna fracture is greatly increased. This paper mainly introduced the diagnosis and treatment of a case of radius and ulna fracture in dog, with an attempt to provide reference for clinical practice.

Diagnosis and Treatment of a Case of Femoral Neck Fracture in Cat

Simple femoral neck fractures in dogs and cats are rare in clinic. The cause of the fracture is that the pelvis or femur is directly or indirectly subjected to external force,and it often occurs secondarily to osteoporosis caused by dysplasia of the hip joint. This paper described the diagnosis and treatment of a blue cat with femora neck fracture.

Diagnosis and Treatment of a Case of Femoral Fracture in Dog

Femoral fracture of dogs is common in daily life. This paper introduced the diagnosis and treatment of a case of femoral fracture in dog, providing reference for clinical practice.

Fibula pro-tibia vs standard locking plate fixation in an ankle fracture saw bone model

BACKGROUND Locking plate fixation in osteoporotic ankle fractures may fail due to cut-out or metalwork failure.Fibula pro-tibia fixation was a technique prior to the advent of locking plates that was used to enhance stability in ankle fractures by achieving tri or tetra-cortical fixation.With locking plates,the strength of this fixation construct can be further enhanced.There is lack of evidence currently on the merits of tibiapro-fibula augmented locking plate fixation of unstable ankle fractures.AIM To assess if there is increased strength to failure,in an ankle fracture saw bone model,with a fibula pro-tibia construct when compared with standard locking plate fixation.METHODS Ten osteoporotic saw bones with simulated supination external rotation injuries were used.Five saw bones were fixed with standard locking plates whilst the other 5 saw bones were fixed with locking plates in a fibula pro-tibia construct.The fibula pro-tibia construct involved fixation with 3 consecutive locking screws applied across 3 cortices proximally from the level of the syndesmosis.All fixations were tested in axial external rotation to failure on an electromagnetic test frame(MTS 858 Mini-Bionix test machine,MTS Corp,Eden Praire,MN,United States).Torque at 30 degrees external rotation,failure torque,and external rotation angle at failure were compared between both groups and statistically analyzed.RESULTS The fibula pro-tibia construct demonstrated a statistically higher torque at 30 degrees external rotation(4.421±0.796 N/m vs 1.451±0.467 N/m;t-test P=0.000),as well as maximum torque at failure(5.079±0.694N/m vs 2.299±0.931 N/m;t-test P=0.001)compared to the standard locking plate construct.The fibula pro-tibia construct also had a lower external rotation angle at failure(54.7±14.5 vs 67.7±22.9).CONCLUSION The fibula pro-tibia locking plate construct demonstrates biomechanical superiority to standard locking plates in fixation of unstable ankle fractures in this saw bone model.There is merit in the use of this construct in patients with unstable osteoporotic ankle fractures as it may aid improved clinical outcomes.