Fractures around Trochanteric Nails: The “Vergilius Classification System”

Introduction. The fractures that occurred around trochanteric nails (perinail fractures, PNFs) are becoming a huge challenge for the orthopaedic surgeon. Although presenting some specific critical issues (i.e., patients’ outcomes and treatment strategies), these fractures are commonly described within peri-implant ones and their treatment was based on periprosthetic fracture recommendations. The knowledge gap about PNFs leads us to convene a research group with the aim to propose a specific classification system to guide the orthopaedic surgeon in the management of these fractures. Materials and Methods. A steering committee, identified by two Italian associations of orthopaedic surgeons, conducted a comprehensive literature review on PNFs to identify the unmet needs about this topic. Subsequently, a panel of experts was involved in a consensus meeting proposing a specific classification system and formulated treatment statements for PNFs. Results and Discussion. The research group considered four PNF main characteristics for the classification proposal: (1) fracture localization, (2) fracture morphology, (3) fracture fragmentation, and (3) healing status of the previous fracture. An alphanumeric code was included to identify each characteristic, allowing to describe up to 54 categories of PNFs, using a 3- to 4-digit code. The proposal of the consensus-based classification reporting the most relevant aspects for PNF treatment might be a useful tool to guide the orthopaedic surgeon in the appropriate management of these fractures.

Magnetic Resonance Imaging in Pelvic Fractures – Part 1: Which Criteria Lead Us to Supplementary MRI Diagnostics?

Introduction Isolated pelvic fractures are relatively rare with an incidence of 3 – 6% of all fractures, but their incidence in polytraumatized individuals increases to 25%. The S3 guideline Polytrauma gives a clear recommendation for diagnostics by means of pelvic radiography (X-ray) and computed tomography (CT). A recommendation for the diagnosis by means of magnetic resonance tomography (MRI) especially in patients with low energetic/missing trauma does not currently exist. It is unclear on the basis of which criteria the MRI can be indicated in pelvic fractures. The aim of our study was therefore to retrospectively record indications for the indication of MRI in pelvic fractures – with adequate as well as inadequate trauma. Material and Methods In a retrospective clinical study, a total of 140 patients (median 68 years, range 15 – 97, 75 female, and 66 male) with a pelvic fracture were included in the study over a period of three years. Overall, the trauma mechanism revealed 73 adequate and 67 inadequate fractures. 31/140 patients had undergone MRI of the pelvis in addition to a CT/X-ray scan. The two subgroups “with MRI” and “without MRI” were analyzed with regard to the parameters “sex”, “age”, “adequacy of the trauma”, “fracture localization”, “duration of admission to imaging”, “type of therapy” and “duration to surgery” compared. Results It was shown that the MRI diagnosis was performed especially in female, elderly patients (81 years, range 19 – 94 years). Patients with inappropriate trauma have received MRI more frequently (74%) than patients with adequate trauma (26%). With regard to fracture localization no differences could be shown. The MRI was performed on a median 4 days after the CT examination. Regarding the decision “conservative” vs. “operationally” our two groups without and with MRT tended to differ not. Patients with MRI were operated on median 2 days later than patients who did not receive MRI. Conclusions Pelvic fracture MRI should be performed primarily in elderly female patients without adequate trauma. In patients with adequate trauma, MRI is of low value, especially as MRI diagnostics are performed with delay, resulting in later surgery.

Draft Recommendations. Pharmacotherapy for the Prevention of Repeated Fractures in Patients with Osteoporosis after Surgical Treatment of Pathologic Proximal Femur Fracture

Treatment of pathologic proximal femur fractures complicating the course of systemic osteoporosis is most often limited by surgical intervention as until now trauma and orthopaedic surgeons have no concrete recommendations on pharmacologic correction of metabolism disorders typical to the pathology, that aggravate in the postoperative period due to operative trauma. Proposed draft recommendations are a part of National clinical recommendations “Treatment for pathologic fractures of skeleton bones complicating the course of osteoporosis”. This issue of recommendations is only applicable to pharmacotherapy directed to the correction of bone tissue remodeling with regard for the fracture localization and volume of surgical intervention. Present recommendations are intended for the improvement of patients’ life quality, reduction of present and future losses from pathologic fracture as well as the prevention of repeated fractures.

Draft Recommendations. Pharmacotherapy for the Prevention of Repeated Fractures in Patients with Osteoporosis after Surgical Treatment of Pathologic Proximal Femur Fracture

Treatment of pathologic proximal femur fractures complicating the course of systemic osteoporosis is most often limited by surgical intervention as until now trauma and orthopaedic surgeons have no concrete recommendations on pharmacologic correction of metabolism disorders typical to the pathology, that aggravate in the postoperative period due to operative trauma. Proposed draft recommendations are a part of National clinical recommendations “Treatment for pathologic fractures of skeleton bones complicating the course of osteoporosis”. This issue of recommendations is only applicable to pharmacotherapy directed to the correction of bone tissue remodeling with regard for the fracture localization and volume of surgical intervention. Present recommendations are intended for the improvement of patients’ life quality, reduction of present and future losses from pathologic fracture as well as the prevention of repeated fractures.

Etiopathogenical criteria in the early diagnosis of Compartmental Syndrome (CS) of the shank

Through the evaluation of some etiopathogenic risk factors one can anticipate the evaluation of some fractures towards Compartmental Syndrome (CS) and then their diagnosis in early stage, when the symptomatology is still unconvincing and the treatment reduces the risk of ischemia lesions. Based both on some prospective observations, using a group of shank fractures, and also on the clinical facts of constituted CS, there were made correlations, statistically reported in the case of some etiopathogenic risk factors represented by the fracture localization and its characteristics, traumatic mechanisms, soft tissue quality and polytraumatism, having an objective common denominator, the compartmental pressure level measured directly. The authors propose an etiopathogenic risk score of CS for the fractures reaching the pressure level of 20-30mmHg, recommending the pressional and clinical monitoring for a score of minimum 10 points. These fractures have a certain risk of CS.