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Background: The tendency toward conservative treatment for clavicle fractures in polytrauma patients may be related to certain characteristics of polytrauma patients. The purpose of this study was to analyze the factors that could affect delayed displacement of fractures during conservative treatment for clavicle fracture in polytrauma patients. Methods: From January 2013 to April 2017, 178 polytrauma patients with an ISS of 16 or more and a clavicle fracture were enrolled from a single trauma center. Of these patients, 79 who had an initial displacement of fractures of less than 100% of the clavicle diameter and initially underwent conservative treatment were included. We analyzed the risk factors that could affect delayed displacement of clavicle fracture by performing a regression analysis of the following factors: patients’ demographic characteristics, location of fracture, presence of comminuted fracture, duration of the intensive care unit stay, ventilator care, initial consciousness level, combined upper extremity injuries, rib fractures of the ipsilateral side, brain injury, and spinal cord injury.Results: A total of 31 patients had delayed displacement of clavicle fracture. The univariable and multivariable logistic regression analyses showed that the statistically significant risk factors for delayed displacement of clavicle fractures were the presence of comminuted fracture and middle third shaft clavicle fracture. Other factors were not statistically related to delayed displacement.Conclusion: Polytrauma patients with clavicle fractures are more likely to develop delayed displacement if there is a presence of comminuted fracture or middle third clavicle fracture. However, polytrauma-related factors did not reduce the risk of delayed displacement of clavicle fractures in polytrauma patients. Level of Evidence: III, retrospective cohort study

We systematically reviewed the incidence of complications and outcomes of different surgical methods for acute perilunate injury in the MEDLINE, Scopus, Embase and Cochrane Library databases. Forty-three articles with 880 patients were included. The most common complications were arthritis (30%), carpal instability (15%), avascular necrosis of the lunate (12%), complex regional pain syndrome (11%), and nonunion or avascular necrosis of the scaphoid (9%). In the meta-analysis, the mean scapholunate gap was 1.7 mm in the closed surgery group and 2.3 mm in the open surgery group, which was a statistically significant difference. The mean flexion–extension arc of the wrist and modified Mayo wrist score were better in the closed surgery group than in the open surgery group. However, these findings may relate to different cohorts in terms of injury severity. Therefore, the causal relationship between closed surgery and better outcomes may be uncertain as less severe subluxations are more likely to be treated closed.

Background Pediatric patients with olecranon fractures are uncommon. The tension band suture technique was introduced to reduce the burden of implant removal and other complications. However, to our knowledge, early range of motion (ROM) exercise has not been introduced in this population of patients. Double Vicryl loops and knots with 2 cross-pins are used to maintain the benefits of the tension band suture technique and to enhance fixation tensile strength. We believe that early ROM exercises could be achieved without nonunion or fixation failure. Methods Twelve pediatric patients with olecranon fractures were treated with tension band suture with double loops and knots between 2004 and 2015. Vicryl No. 1 was used for wiring. ROM exercises were initiated 1 week postoperatively with a customized functional brace. Early functional outcomes were evaluated by the Mayo Elbow Performance Score at every visit after 8 weeks postoperatively. Results Nine boys and 3 girls (average age, 10.6 years; range, 5 years 7 months–16 years 2 months) were included in the study. Initial displacement and angulation of the fractures were 5 mm (2-7 mm) and 12° (4°-25°), respectively. Two cases had radial neck fractures of the ipsilateral elbow. All patients had a perfect Mayo Elbow Performance Score after 8 weeks postoperatively. Pin removals were performed at 13.1 weeks. No complications, including growth arrest, were observed. Discussion/Conclusion Tension band suture with double loops and knots, combined with early ROM exercise, may be a complete alternative to tension band wiring.

To introduce a stepwise percutaneous leverage technique to avoid posterior interosseous nerve (PIN) injury in pediatric patients with radial neck fractures and to evaluate the clinical outcome and the predisposing factors affecting the outcome.Retrospective case series study.University level 1 trauma center.Thirty-four children with a radial neck fracture, who were treated using a stepwise percutaneous leverage technique, were included in the study.The radial head fragment was reduced by pulling the first Steinmann pin proximally as a lever. Then, the kinked soft tissue was released by removal of the Steinmann pin with buttressing the radial head by the operator's thumb. The second Steinmann pin was inserted into relaxed soft tissue for fixation of the radial head.We used the Métaizeau classification as a radiologic result and Mayo Elbow Performance Score (MEPS) as a clinical outcome. Regression analysis was performed to identify the predisposing factors affecting the outcome.There was no occurrence of PIN palsy. According to the Métaizeau classification, 23 cases were classified as excellent, 9 as good, 1 as fair, and 1 as poor. The average MEPS was 97.6 points. Based on the regression analysis, only the postoperative Métaizeau classification was confirmed as a risk factor of a relatively poor outcome.The stepwise percutaneous leverage technique can be considered a good option in the treatment of pediatric radial neck fractures, because it ensures excellent results by avoiding injury to soft tissues including the PIN.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purpose To evaluate the time to bone union after open reduction and internal fixation with cerclage cables followed by intramedullary nailing (IMN) for unstable humeral shaft fractures. Materials and Methods Patients with a humeral shaft fracture treated by IMN were enrolled. One group of patients was treated via open reduction and internal fixation with cables followed by IMN (cable group; n=32), while the other group was treated with a conventional closed IMN (non-cable group; n=64). The length of time to bone union and functional scores [Disabilities of the Arm, Shoulder and Hand (DASH) and University of California, Los Angeles (UCLA) scores] were measured for all patients. Results No significant differences were found in terms of age, gender, injury type, or smoking history between the two groups, except for the type of fracture. The cable group had significantly more complex types of fracture than the non-cable group (p0.05). No differences were identified in terms of DASH and UCLA scores (28.8 and 32.1 in the cable group and 26.4 and 32.6 in the non-cable group, respectively; p=0.335 and 0.264). Conclusion In unstable humeral shaft fractures treated by IMN, open reduction and internal fixation with additional cerclage cables do not delay the length of time to bone union or increase the rate of other complications.

There has been a tremendous amount of research in the past decade to optimize the mechanical properties and degradation behavior of the biodegradable Mg alloy for orthopedic implant. Despite the feasibility of degrading implant, the lack of fundamental understanding about biocompatibility and underlying bone formation mechanism is currently limiting the use in clinical applications. Herein, we report the result of long-term clinical study and systematic investigation of bone formation mechanism of the biodegradable Mg-5wt%Ca-1wt%Zn alloy implant through simultaneous observation of changes in element composition and crystallinity within degrading interface at hierarchical levels. Controlled degradation of Mg-5wt%Ca-1wt%Zn alloy results in the formation of biomimicking calcification matrix at the degrading interface to initiate the bone formation process. This process facilitates early bone healing and allows the complete replacement of biodegradable Mg implant by the new bone within 1 y of implantation, as demonstrated in 53 cases of successful long-term clinical study.

OBJECTIVE:: This study was conducted to categorize barefoot stubbing injuries to the great toe in children by injury mechanism in order to differentiate benign stubbing injuries from more complex injuries necessitating surgery. DESIGN:: Prospective clinical series of consecutively treated patients SETTING:: Tertiary university hospital setting. PATIENTS:: Forty-one children who had sustained an indirect injury to the great toe during barefoot sports activities between January 2001 and December 2009 were included. INTERVENTION:: Conservative or surgical treatment was done according to clinical and radiologic findings. MAIN OUTCOME MEASUREMENT:: Information regarding injury mechanism was collected from patients, parents and coaches using skeletal models and assessed by a pediatric orthopedic surgeon. Mechanisms of injury were identified and grouped as follows: hyperabduction-flexion, hyperflexion, hyperabduction-extension, hyperextension, and hyperextension-adduction. RESULTS:: Hyperabduction-flexion was the most common mechanism (n=16), in which interphalangeal joint dislocation and skin disruption was noted in most cases. The second most common mechanism was hyperabduction-extension (n=14) in which avulsion fracture of the lateral volar condyle of the proximal phalanx was noted in most cases. This avulsion fracture had the worst prognosis after conservative care. CONCLUSION:: Based on these results, we have created a grading system and treatment protocol for indirect hallux sports injuries in children. Avulsion fracture of the lateral condyle of the proximal phalanx, a result of hyperabduction-extension, is a high risk sign of nonunion and should be aggressively treated, contrary to previous guidelines. LEVEL OF EVIDENSCE:: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. Language: en

Treatment of comminuted fractures of the radial head is controversial, and considerable effort has been made to restore optimal function of the elbows, either by surgical reconstruction or prosthetic replacement. This report presents our experiences in treatment of unreconstructable radial head or neck fractures using osteochondral autografts harvested from the base of the second metatarsal bones.Five patients with radial head and one with a radial neck fracture underwent treatment with osteochondral autografts. After excision of the unreconstructable radial head, the second metatarsal base was harvested and transplanted to the radius using the intramedullary nailing technique.The reconstructed elbows were examined clinically and radiographically for a mean period of 44.8 months (range, 24-72 months). At the last follow-up, in flexion-extension, the mean elbow mobility was 130°/10°. In supination-pronation, the mean elbow mobility was 73.3°/66.7°, with a mean loss of supination of 19.2° and loss of pronation of 12.5°. Grip strength was 91%, compared with the contralateral limb. The mean Mayo Elbow Performance Score was 94.2. The mean score of AOFAS rating system to the lesser toe was 93.7 points.Radial head arthroplasty with an osteochondral autograft from the second metatarsal base appears to be an effective alternative for treatment of unreconstructable radial head fractures. A larger group of patients and a longer follow-up period will be required in order to ease concerns regarding the donor site; however, none of the patients who underwent this procedure showed any complications during follow-up.

The trabecular microstructure of normal lunates and lunates with Kienböck’s disease was investigated using micro-computed tomography (micro-CT). Five lunates with advanced Kienböck’s disease were obtained during lunate excision and scaphocapitate fusion, and five control lunates were from embalmed cadavers. Microstructural morphometric parameters were measured using micro-CT images. Trabeculations of lunates with Kienböck’s disease were 2.67 times denser and 1.84 times thicker than those of normal lunates. Furthermore, bone surface areas were 1.43 times greater and bone volume 2.67 times greater, and structural model indices were significantly lower in lunates with Kienböck’s disease. The study estimated that high mechanical stress would be applied to lunates with Kienböck’s disease, and suggests that new bone formation and collapse may play important roles in the microstructural changes in the lunate with advanced Kienböck’s disease.

Isolated volar fracture-dislocation of the second carpometacarpal joint is extremely rare, and no case of indirect injury has been reported. We are presenting a case of indirect injury, treated by open reduction with volar approach. Three-dimensional computed tomography was helpful for confirming and making surgical plan for this injury.

We report a case of simultaneous reconstruction of a quadriceps tendon rupture after total knee arthroplasty (TKA) and neglected Achilles tendon rupture, which occurred before TKA with an ipsilateral hamstring autograft. A 64-year-old woman presented with persistent right knee pain. She also had right heel pain and had received multiple steroid injections at the knee joint and heel. On examination, she showed osteoarthritis in the medial and lateral compartments of the knee joint and an Achilles tendon rupture in the ipsilateral limb. There was skin dimpling and the proximal portion of tendon was migrated. We performed TKA, and the postoperative course was satisfactory. She returned 3 months postoperatively, however, with skin dimpling around the suprapatellar area and weakness of knee extension. Her ankle symptoms were also aggravated because she could not use the knee joint freely. We performed simultaneous reconstruction of the quadriceps tendon and the Achilles tendon using an ipsilateral hamstring autograft. Hamstring autograft offers a good alternative treatment option for rupture repair, particularly with concommitant ruptures of multiple sites when primary repair is not possible or the viability of repaired tissue is poor.

Strangulation around cuff tissue is a possible cause of retear after rotator cuff repair. Therefore, tendon healing ideally requires changes in suture tension over the cuff tissue in accord with rotator cuff muscle activity. The authors present a type of fixation that mimics the mechanism of the Chinese finger trap. The devised knot-free tendon trap technique resembles the double-pulley–suture bridge technique, but all suture limbs share the tension evenly and respond synchronized to the cuff tendon. The technique provides simple biologic repairs of rotator cuff tears.

This study examined the relationship between the presence of a pit above the lesser tuberosity on axial view radiographs and rotator cuff tears and compared the demographic data between groups according to the presence of a pit above the lesser tuberosity. The hypothesis of this study was that the radiographic finding of a pit above the lesser tuberosity is related to rotator cuff tears. For 112 patients with a symptomatic rotator cuff tear, plain radiographs of the symptomatic shoulder (tear side radiographs) and plain radiographs of the asymptomatic contralateral shoulder (no-tear side radiographs) were assessed. Seventeen radiological findings, including a pit above the lesser tuberosity, osteophytes, subchondral cysts, and sclerosis, were recorded by one blinded observer. Demographic data such as age, duration of symptoms, sex, arm dominance, smoking history, trauma history, American Shoulder and Elbow Surgeons score, Constant score, and involved tendon were collected. A pit above the lesser tuberosity was noted on tear side radiographs of 40 patients (35.7 %) and on the no-tear side radiographs of 27 patients (24.1 %), representing a significant difference (P = 0.040). A pit associated with a rotator cuff tear was observed more often in the dominant arm (P = 0.040) and more often in patients with less previous trauma (P = 0.024). A pit above the lesser tuberosity on axial view radiography was associated with a rotator cuff tear and occurred more often in the dominant arm of patients who had no trauma history. Prognostic study, Level III.

Goniometers can be used to assess shoulder ROM with reasonable accuracy, but not internal rotation. Vertebral level, as determined by the hand-behind-the-back method, is used frequently but its reproducibility is questionable. We therefore devised a new measuring tape-based method for determining vertebral level.We (1) compared the accuracy of a measuring tape-based and conventional vertebral-level method; (2) determined whether BMI affects their accuracy; and (3) devised a formula for converting distances measured using a measuring tape to vertebral levels.We assessed internal rotation in 61 patients with shoulder pain. An electrode was taped to the skin where the thumb reached maximally behind the back. The vertebral-level method involved determining the vertebral level of the electrode by palpating bony landmarks whereas the measuring tape method involved measuring the distance between the C7 spinous process and the electrode. True vertebral levels of the electrode were confirmed by radiography.In nonobese patients, the accuracies of the upper thoracic and lumbar-level measurements were better for the measuring tape method than the vertebral-level method (r = 0.861 and 0.700, respectively in upper thoracic; 0.913 and 0.710, respectively in lumbar). Patient BMI affected the accuracy of the vertebral-level method but not that of the measuring tape method. The distances obtained using the measuring tape method could be converted into vertebral-level units using the formula: estimated vertebral level = 0.031 × [distance between C7 spinous process and thumb behind back] - 0.044 × [patient height] + 7.277.The measuring tape-based method reflected shoulder internal rotation with higher accuracy than the vertebral-level method, and unlike the vertebral-level method, the measuring tape method was not affected by obesity.Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

The authors describe two cases of subacromial impingement syndrome of the shoulder secondary to scapular dyskinesia caused by a tumor in young adults. The two tumors, an osteochondroma and a ganglion, were located in the scapulothoracic joint and inhibited normal kinesis of the scapula during arm motion.

Intraneural ganglion cysts of the peripheral nerve in the upper extremity are uncommon and usually originate within the epineurium of the peripheral nerve. The current report discusses a 57-year-old woman with a neuropathic nodular mass on the thenar area of the left hand. Magnetic resonance images showed a lobulated, homogeneous mass of high signal intensity on T2-weighted images and low signal intensity with peripheral enhancement on T1-weighted images. Excisional biopsy and histopathologic examination confirmed an intraneural ganglion cyst of the digital nerve of the thumb. A successful result was obtained by surgical treatment, and there was no recurrence of abnormal sensation and paraesthesia during the 3-year follow-up period.

Recently, as the scale, structure, capacity and use of buildings are more complicated in construction projects, it is more difficult to estimation project’s costs. Because its project’s scale is much bigger than any other project’s one and total project cost is concluded after project is finished, it is important to make cost estimation method and system. In past, it is possible to estimate cost only using simple method. But, to cope with the now and future situation, it is necessary to have to study not only method but also database. In this paper, using real structure data of Korea public residential buildings, we discuss cost estimation based on the quantity of material at design stage. To estimate costs accurately under complicated situations, After selecting influence factors, cost database, named Database Layer, is created. And then, cost model is suggested using Case-Based Reasoning and Regression. This paper is expected to improve the accuracy and contribute to estimation studies under various conditions.

Traumatic bone extrusion followed by successful bone-segment reimplantation is uncommon1-4. When bone loss is minimal, open fractures may heal by stabilization alone, and small amounts of bone loss can generally be treated with an autogenous or allogenic bone graft. Large segmental bone defects may occur at the time of injury or after surgical debridement of devitalized bone, and may require large grafts, multiple grafts, vascularized bone grafts, or bone transport5-7. The benefits of reimplanting an extruded segment include maintenance of the original skeletal structure, avoidance of morbidity associated with autogenous bone harvesting, and avoidance of allograft bone procedures or prolonged bone transport procedures. Regardless of the sterilization method used, reimplantation of a devascularized bone segment after meticulous wound debridement and sound bone stabilization is associated with an elevated risk of infection. However, the literature lacks guidelines regarding the sterilization, timing of reimplantation, and stabilization of extruded bone segments1-4. We describe a case of early reimplantation of an extruded humeral segment in a child. The patient and her family were informed that data from this case would be submitted for publication, and they provided consent. A three-year-old girl fell from a third-floor balcony of an apartment and sustained an injury to the right arm and elbow. Her general condition was good, and she was alert and oriented. Other injuries included only a small scalp laceration and multiple superficial abrasions over the lower extremities. Physical examination revealed a 3-cm transverse laceration on the posterior aspect of the distal part of the right arm (just proximal to the olecranon) with moderate contamination, and gross motion indicating skeletal instability. A missing segment of humerus measuring 7.5 cm was retrieved by the parents from the scene approximately sixty minutes after the accident. The …

We would like to present a case of pseudoaneurysm of the anterior tibial artery after closed intramedullary nailing of a tibial shaft fracture.In an automobile accident, a 56-year-old man sustained a transverse diaphyseal fracture of the left tibia. 10 days after closed intramedullary nailing with laterally inserted proximal and distal locking screws, an enlarging tender, pulsating mass was found over the anterolateral aspect of his left leg. Ultrasonography and angiography revealed a pseudoaneurysm of the anterior tibial artery at the level of the distal locking screw. Surgical resection of the injured segment of the anterior tibial artery associated with a pseudoaneurysm and a vein graft was performed.