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Patellar fracture is a common injury caused by excessive tension through the extensor mechanism or a direct blow. The intact patella increases the leverage and efficiency of the extensor mechanism and articulates with the femoral trochlea. Patellar fractures can lead to stiffness, extension weakness, and patellofemoral arthritis. Nonsurgical management is indicated for nondisplaced fractures with an intact extensor mechanism. Surgical fixation is recommended for fractures that either disrupt the extensor mechanism or demonstrate >2 to 3 mm step-off and >1 to 4 mm of displacement. Anatomic reduction and fixation with a tension-band technique is associated with the best outcomes; however, symptomatic hardware is a frequent complication. Open fractures are associated with more complications than closed fractures. These complications can be mitigated with timely debridement, irrigation, and internal fixation.

A 53-year-old woman presented with 3 months of progressively worsening right medial thigh pain. She reported having constant severe pain and a burning sensation in the upper thigh. Her pain was worse at night, often awakening her from sleep. Initially, she experienced some relief with aspirin, ibuprofen, and naproxen; however, these no longer provided relief. She obtained partial pain relief with acetaminophen. She had a history of mild, blunt trauma to the left torso approximately 1 month before presentation, but no history of trauma to the affected limb. She denied any back pain, fever, chills, night sweats, or weight loss. Physical examination revealed a well-developed woman with no obvious deformity. Right antalgic gait was noted. There was no edema, erythema, skin warmth, or palpable mass on examination of the right thigh. Deep palpation did not change her symptoms. There was full and painless active and passive range of motion of the right hip and knee. Neurovascular examination, strength, and tone were normal. Magnetic resonance images of the right hip and thigh (Fig. 1), CT scans of the right proximal femur (Fig. 2), and a total body bone scan (Fig. 3) were available from the referring physician. Plain radiographs had not been performed at the time of the initial evaluation. Based on the history, physical examination, and the imaging studies, what is the differential diagnosis?

Between 2001 and 2011, 1168 revision hip arthroplasties were reviewed for “early” failures within 5 years of the primary total hip arthroplasty (THA). 24.1% underwent revision within 5 years of index THA. Aseptic loosening, infection, instability, metallosis, and fracture were common modes of failure. In our previous report from 1986 to 2000, 33% were “early” revisions, with instability and aseptic loosening accounting for over 70% of these early failures. While the proportion of “early” revisions decreased 9% from our previous report, this rate remains alarming. The emergence of metallosis and aseptic loosening of monoblock metal on metal shells as leading causes of early failures is concerning. This report suggests caution in the early adoption of new innovations before evidence based medicine is available to justify the risk of their use.

As the number of hip arthroplasties performed continues to grow, increasingly complex periprosthetic fractures are encountered. In particular, fractures occurring near the tip of a well-fixed stem, classified as Vancouver B1, have been associated with high rates of failure. Numerous treatment strategies have been recommended including traditional plating, locked plating, cortical allografts as well as retrograde nails overlapping the femoral stem tip. The latter technique has been advocated as a less invasive method to stabilise periprosthetic fractures in elderly, lowdemand patients unfit for extensive surgical procedures. Here, we present the use of a retrograde nail overlapping a femoral stem in a young, active patient as supplemental fixation to a lateral plate for the difficult situation of a Vancouver B1 periprosthetic fracture proximal to an femoral shaft hypertrophic nonunion.

Fractures of the shoulder and elbow are common in the elderly population. Osteopenia and osteoporosis put this population at risk for fractures from low-energy trauma. The majority of fractures of the shoulder and elbow in this population are best managed nonoperatively. However, surgical intervention with open or closed reduction with fixation, shoulder arthroplasty, or total elbow arthroplasty may offer more predictable and better functional outcomes for certain fracture patterns. Regardless of the treatment modality, the goal of treating these injuries is to provide stable fracture fixation or reconstruction allowing early mobilization and pain free upper extremity function.

Definitive treatment of open fractures of the tibial diaphysis is challenging. The high-energy nature of these fractures, as well as the contamination of the fracture site and devitalization of the soft-tissue envelope, greatly increases the risk of infection, nonunion, and wound complications. The goals of definitive treatment include wound coverage or closure; prevention of infection; restoration of length, alignment, rotation, and stability; fracture healing; and return of function. Advances in orthobiologics, modern plastic surgical techniques, and fracture stabilization methods, most notably locked intramedullary nailing, have led to improved prognosis for functional recovery and limb salvage. Despite improved union and limb salvage rates, the prognosis for severe type III open fracture of the tibial shaft remains guarded, and outcomes are often determined by patient psychosocial variables.

OBJECTIVE. The purpose of this article is to present the cases of four consecutive patients with preoperative MR diagnosis of humeral avulsion of the glenohumeral ligament (HAGL) who had no evidence of HAGL at arthroscopy.CONCLUSION. These four cases suggest that the diagnosis of HAGL should be reserved for arthroscopy and illustrate the difficulty in distinguishing HAGL from other abnormalities of the inferior glenohumeral ligament complex with MRI. Thus, MRI findings classically associated with HAGL should be more broadly described as defects of the inferior glenohumeral ligament complex. This terminology more accurately describes the abnormalities of the inferior glenohumeral ligament complex that may be depicted by MRI.