Objective: The goal of the study is to diagnose and accurately correct malrotation of femur fractures after intramedullary (IM) nailing.Materials and methods: An institutional review board (IRB) approved prospective study that was performed at a U.S. level 1 trauma center. After IM nailing of comminuted femur fractures, a computed tomography (CT) scanogram was routinely performed to detect the difference in the postoperative femoral version. Patients with malalignment greater than 15 degrees compared to the contralateral side were informed about the discrepancy and offered to have it acutely corrected. A four-pin technique was used: two Schanz pins were used for measuring angles and two different pins were used to turn and correct the malalignment. The pin in the distal fragment is placed directly under the nail to prevent shortening in comminuted fractures. The nail was unlocked either proximally for retrograde nails or distally for antegrade nails. The Bonesetter Angle application was used as a digital protractor to intraoperatively measure the two reference pins and correct the malrotation. Alternate holes were used for relocking the nail. All patients received a CT scanogram after correction.Results: 19/128 patients with comminuted femoral fractures over five years with malrotations between 18 and 47 degrees were included in the study with an average malrotation of 24.7 + 8 degrees. All patients were corrected to an average of 4.0 +/-2.1 degrees difference, as compared to the contralateral side (range 0-8). No patients required further surgeries to correct malrotation. Conclusion: Comminuted fractures with malrotation >15 degrees after femoral nailing have an incidence of 15% at our institution. This technique provides an efficient and accurate correction method with the use of an intraoperative digital protractor, avoiding the need for revision IM nailing or osteotomies.
In supination external rotation (SER) ankle fractures with an intact medial malleolus, stability hinges upon the competence of the deltoid ligament. The purpose of this study is to define the indications and establish criteria for a positive stress radiograph. MethodsThis is a prospective study of 27 isolated SER lateral malleolar fractures with a reduced ankle mortise. Pain and swelling were noted about the medial ankle, followed by an ultrasound to evaluate the integrity of the deltoid ligament. Static and stress radiographs were performed on both the fractured and contralateral ankles. ResultsFourteen patients were normal on ultrasound examination, eight had partial tears, and five had fullthickness tears. The difference in the level of pain to palpation postero-medially between the complete tear (7 +/-1) and the partial tear (1.3 +/-2.4) group was significant (p < .001). The negative predictive values for medial swelling and tenderness were 93% and 100%, respectively. Sensitivity and specificity for medial clear space on stress radiograph (fracture (fx)) > 5.0 mm were both 100% while a 2.5 mm or greater change to the contralateral side yielded a sensitivity of 100% and specificity of 95%. ConclusionThe lack of significant medial pain, as well as swelling, implies the absence of a complete ligament tear and eliminates the need for stress examination. Conversely, the presence of medial signs of injury is suggestive, but not pathognomonic for a complete deltoid tear. Medial clear space (MCS) variability prompts to recommend a minimum of 2.5 mm on stress radiographs compared to the contralateral side as indirect evidence for a complete tear of the deltoid ligament.
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