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Orthopaedic Journal of Sports Medicine Sep 2023There is no consensus regarding the management of posterior cruciate ligament (PCL) avulsion fractures and the expected outcomes after treatment. (Review)
Review
BACKGROUND
There is no consensus regarding the management of posterior cruciate ligament (PCL) avulsion fractures and the expected outcomes after treatment.
PURPOSE
To systematically review clinical outcomes and complications after management of tibial-sided avulsion fractures of the PCL.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A literature search of Scopus, PubMed, Medline, and the Cochrane Central Register for Controlled Trials was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included were studies with evidence levels 1 to 4 that reported clinical outcomes after treatment of PCL tibial-sided avulsion fractures in humans. The quality of the included studies was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. A meta-analysis was performed for patient-reported outcome measures using random-effects modeling with 95% CIs.
RESULTS
A total of 58 studies published between 1999 and 2022 were identified. The mean MINORS score was 9.90 ± 4.12, indicating overall low-quality evidence with high risk of bias. The studies comprised 1440 patients (mean age, 32.59 ± 5.69 years; 75.2% males) with a mean follow-up of 26.9 ± 19.6 months (range, 5.3-126 months). Most patients were treated with open surgery (63.6%), followed by arthroscopic surgery (29.7%) and nonoperative treatment (6.7%). All patients reported significant posttreatment improvement in both subjective and objective outcomes ( < .05 for all). Arthroscopic surgery was associated with lower postoperative posterior tibial translation compared with open surgery (range, 0.6-3.2 vs 1.7-3.1 mm), greater preoperative to postoperative improvement in Lysholm score (54.6 vs 48.8; < .0001), higher postoperative Tegner score (6.64 ± 1.03 vs 6.14 ± 2.29; = .0448), and a higher rate of return to sport (100% vs 89.5%; = .009). Nonoperative management was associated with a significantly lower fracture union rate (87% vs 99.1%; < .0001) and greater postoperative side-to-side posterior translation (4.9 ± 4.3 mm) when compared with operative management.
CONCLUSION
Although nonoperative and surgical management of PCL tibial avulsion fractures resulted in high rates of fracture union and improvement in functional outcome scores and a low incidence of complications, nonoperative treatment yielded a high side-to-side posterior displacement (>4 mm) with a lower rate of fracture union compared to surgical treatment.
PubMed: 37724253
DOI: 10.1177/23259671231188383 -
JSES Reviews, Reports, and Techniques Aug 2021Although fracture of the coracoid process (CF) used to be considered rare, it is now more commonly encountered due to increased awareness and advances in imaging... (Review)
Review
BACKGROUND
Although fracture of the coracoid process (CF) used to be considered rare, it is now more commonly encountered due to increased awareness and advances in imaging methods. This review aimed to analyze reported cases of CF to determine its mechanism and appropriate treatment.
METHODS
PubMed and Scopus were searched using the terms "scapula fracture" and "coracoid fracture." The inclusion criteria were English full-text articles concerning CF that described patient characteristics with appropriate images. The exclusion criteria included cases without appropriate images and those with physeal injury or nonunion. Citation tracking was conducted to find additional articles and notable full-text articles in other languages. Fractures were mainly classified using Ogawa's classification.
RESULTS
Ninety-seven studies were identified, including 197 patients (131 men, 33 women; average age 37.0±16.9 years). CF was classified as type I in 77%, type II in 19%, and avulsion fracture at the angle in 5%. Concurrent shoulder girdle injuries included acromioclavicular injury in 33%, clavicular fracture in 17%, acromion or lateral scapular spine fracture in 15%, and anterior shoulder instability in 11%. Among patients with type I CF, 69% had multiple disruptions of the superior shoulder suspensory complex. Conservative treatment was applied in 71% of isolated type I CF, while surgical treatment was applied in 76% of type I CF with multiple disruptions. Although the evaluation methods varied, 60% of patients were followed up for more than 6 months, and the outcomes were generally satisfactory for both conservative and surgical treatments.
CONCLUSION
CF occurred commonly in the age group with higher social activity. The most common fracture type was type I. The possible mechanism of CF is violent traction of the attached muscles, except for avulsion fracture at the angle. Type I CF with multiple disruptions of the superior shoulder suspensory complex requires surgical treatment, whereas conservative care is recommended for isolated type I and type II CFs.
PubMed: 37588963
DOI: 10.1016/j.xrrt.2021.04.008 -
Orthopaedic Journal of Sports Medicine May 2022Arm wrestling is a popular sport in which various injuries have occurred, even in children. (Review)
Review
BACKGROUND
Arm wrestling is a popular sport in which various injuries have occurred, even in children.
PURPOSE
To analyze reported fracture-separation of the medial humeral epicondyle (MHE) caused by arm wrestling to determine its mechanism and provide a current overview.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
The PubMed and Web of Science databases were searched using the terms "arm wrestling" and "humeral fracture" or "medial humeral epicondyle fracture"; and "sports" and "humeral fracture" or "medial humeral epicondyle fracture," following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were English full-text articles on arm wrestling-induced MHE fracture that described patient characteristics and presented appropriate images. Studies with a lack of appropriate images or detailed description of the injury situation were excluded. The patient characteristics were evaluated, and the ratios of treatment selection and outcomes were evaluated using the chi-square test.
RESULTS
Included were 27 studies with a total of 68 patients, all boys with a mean age of 14.6 ± 1.24 years (based on n = 65, with 3 patients excluded from this calculation as no definitive age was provided). Boys aged 14 to 15 years accounted for 72% (49/68) of the cases. Fracture occurred suddenly during arm wrestling in 63 boys, while the other 5 boys experienced antecedent medial elbow pain. The match status at the time of injury, provided for 46 patients, was varied. In 31 boys with known match details, injury occurred when a participant suddenly added more force to change the match status. Eight patients displayed anterior and/or proximal displacement of the MHE fragment. Treatment was nonoperative in 25 patients and operative in 38 patients (n = 63, excluding 5 unknown patients). In 35 patients followed up for ≥3 months (mean, 17.6 ± 12.3 months), outcomes were not significantly different between the operative and nonoperative groups.
CONCLUSION
MHE fracture-separation caused by arm wrestling occurred mostly in boys aged 14 to 15 years regardless of the match status. The likely direct cause is forceful traction of the attached flexor-pronator muscles. A relative mechanical imbalance during adolescence may be an underlying cause. A sudden change from concentric to eccentric contraction of the flexor-pronator muscles increases the likelihood of fracture occurrence.
PubMed: 35528993
DOI: 10.1177/23259671221087606 -
JSES Reviews, Reports, and Techniques May 2022The terrible triad of the elbow (TTE) is a complex injury consisting of simultaneous elbow dislocation or subluxation, radial head fracture, and coronoid fracture.... (Review)
Review
BACKGROUND
The terrible triad of the elbow (TTE) is a complex injury consisting of simultaneous elbow dislocation or subluxation, radial head fracture, and coronoid fracture. During the initial assessment of a TTE, the typical severity of presenting pain, swelling, and limited range of motion may limit the ability to perform a thorough physical examination and thus divert a clinician's attention away from additional injuries to the ipsilateral upper extremity. Therefore, the purpose of this study was to review the literature for reported cases of concomitant ipsilateral upper extremity injuries associated with a TTE and discuss various strategies to increase clinician awareness to avoid underdiagnosis and missed diagnoses.
METHODS
A systematic review of five databases in four languages (English, Spanish, French, and Portuguese), from inception to May 2021, was conducted. Articles describing a TTE with a concomitant osseous, chondral, ligamentous, or musculotendinous injury occurring on the ipsilateral upper extremity were included. The patients were divided into two groups, those presenting with a classic TTE and concomitant ipsilateral upper extremity injury (group 1) and those in whom a TTE variant was described (group 2). A TTE variant was defined as a combination of osseous and/or chondral injuries to the elbow other than the classic description of TTE, in which at least two of the three classical elements of a TTE (elbow dislocation, coronoid fracture, and radial head fracture) were present in addition to other unique elbow osteoarticular injury.
RESULTS
Nineteen articles met inclusion criteria and were further analyzed. A total of 27 patients were analyzed, 23 from group 1 and 4 from group 2. Overall, 33 concomitant injuries were documented in group 1, the most common being an olecranon fracture (27.3%), followed by Essex-Lopresti injury, triceps tendon avulsion, and carpal fracture-dislocation with 4 (12.1%) cases each. Group 2 had four patients, all of whom presented with a unique variant of the classically described TTE.
CONCLUSION
Despite a characteristic radiographic appearance of the classic TTE, additional injuries of the ipsilateral extremity or variants of the classic TTE may be easily missed, especially in cases resulting from high-energy mechanisms of injury. By analyzing the available data on associated injuries and variants that may occur with a TTE, we hope to increase awareness so that clinicians may recognize these less common but more complex injury patterns.
PubMed: 37587951
DOI: 10.1016/j.xrrt.2021.10.004 -
Orthopaedic Journal of Sports Medicine Apr 2022Although arthroscopic screw fixation and suture fixation are mainstream interventions for displaced anterior cruciate ligament avulsion fractures of the tibia, the... (Review)
Review
Functional Outcomes and Subsequent Surgical Procedures After Arthroscopic Suture Versus Screw Fixation for ACL Tibial Avulsion Fractures: A Systematic Review and Meta-analysis.
BACKGROUND
Although arthroscopic screw fixation and suture fixation are mainstream interventions for displaced anterior cruciate ligament avulsion fractures of the tibia, the differences in clinical outcomes between them remain inconclusive.
PURPOSE
To conduct a meta-analysis comparing the clinical and functional outcomes between arthroscopic screw fixation and suture fixation for tibial avulsion fractures.
STUDY DESIGN
Systematic review; Level of evidence, 3.
METHODS
A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Inclusion criteria were English-language articles that compared functional outcomes after screw fixation versus suture fixation for tibial avulsion fractures and had at least 1-year follow-up. Relevant data were extracted and analyzed statistically using the Mantel-Haenszel method and variance-weighted means. Random-effects models were used to generate pooled relative risk (RR) estimates with confidence intervals (CIs).
RESULTS
Of 1395 articles initially identified, we included 5 studies with 184 patients (91 patients with screw fixations and 93 patients with suture fixations). The pooled results indicated similar postoperative outcomes for screw fixation and suture fixation: Lysholm score (mean difference [MD], -0.32 [95% CI, -6.08 to 5.44]; = .91), proportion of International Knee Documentation Committee score grade A (74% vs 74%; RR, 0.63 [95% CI, 0.10-3.95]; = .63), Tegner score (MD, 0.10 [95% CI: -1.73 to 1.92]; = .92), and Lachman test results (stable knee joint, 82% vs 82%; RR, 0.99; 95% CI: 0.85-1.16; = .90). Patients in the screw fixation group had a significantly higher overall subsequent surgery rate (46% vs 19%; RR, 2.33; 95% CI,1.51-3.60; = .0001) and implant removal rate (44% vs 3%; RR, 8.52; 95% CI, 3.58-20.29; < .00001) compared with those in the suture fixation group. Nonimplant-related subsequent surgery rates were similar for the 2 groups.
CONCLUSION
The findings indicated a higher risk of subsequent surgery (RR, 2.33) and implant removal (RR, 8.52) after screw fixation when compared with suture fixation for tibial avulsion fractures. However, there were no significant differences in clinical outcome scores between the 2 techniques.
PubMed: 35400137
DOI: 10.1177/23259671221085945 -
Frontiers in Pediatrics 2022Avulsion fractures of the pelvis and hip region are typical injuries in adolescent athletes. Avulsion sites include the muscle tendon origin or insertion, and treating...
Avulsion fractures of the pelvis and hip region are typical injuries in adolescent athletes. Avulsion sites include the muscle tendon origin or insertion, and treating these injuries surgically or conservatively remains a debated issue. The main goals of this review were to assess and summarize injury types and sites, treatment-related clinical outcomes, and return to sport for adolescent patients with a pelvis avulsion fracture and to provide support for making treatment decisions. The PubMed database was searched in November 2021 to identify all published articles from 2000 to 2021 that reported the outcome and return to sport after conservative or surgical treatment. Eighteen studies with 453 patients were included in this review. The age range was 13.6-16.8 years. The most common injury site the was anterior superior iliac spine (37%), followed by the anterior inferior iliac spine (31%), ischial tuberosity (14%), lesser trochanter (9%), iliac crest (8%), and superior corner of the pubic symphysis (1%). Overall complications were lower in the surgical group compared to the conservative group. The rate of return to pre-injury activity level was greater in patients who underwent surgical treatment ( < 0.05). In conclusion, surgery is preferred for major dislocation and fragment size, providing a better return-to-sport rate and decreasing the risk of complications.
PubMed: 36210934
DOI: 10.3389/fped.2022.947463 -
British Medical Bulletin Jun 2016Arthroscopy procedures are the gold standard for the management of tibial spine avulsion. This review evaluates and compares different arthroscopic treatment options for... (Review)
Review
INTRODUCTION
Arthroscopy procedures are the gold standard for the management of tibial spine avulsion. This review evaluates and compares different arthroscopic treatment options for tibial spine fractures.
SOURCE OF DATA
PubMed, Medline, Ovid, Google Scholar and Embase databases were systematically searched with no limit regarding the year of publication.
AREAS OF AGREEMENT
An arthroscopic approach compared with arthrotomy reduces complications such as soft-tissue lesions, post-operative pain and length of hospitalization.
AREAS OF CONTROVERSY
The use of suture techniques, compared to cannulated screw technique, avoids a second surgery for removal of the screws, but requires longer immobilization and partial weight bearing.
GROWING POINTS
Clinical outcomes and radiographic results do not seem to differ in relation to the chosen method of fixation.
AREAS TIMELY FOR DEVELOPING RESEARCH
Further studies are needed to produce clear guidelines to define the best choice in terms of clinical outcomes, function and complications.
Topics: Arthroscopy; Bone Screws; Fracture Fixation, Internal; Fracture Healing; Humans; Length of Stay; Pain, Postoperative; Radiography; Reproducibility of Results; Soft Tissue Injuries; Suture Techniques; Tibial Fractures; Treatment Outcome; Weight-Bearing
PubMed: 27151952
DOI: 10.1093/bmb/ldw018 -
Journal of Shoulder and Elbow Surgery Apr 2021Fractures of the anteromedial facet (AMF) of the coronoid process are caused by a varus posteromedial rotational injury force, leading to instability in the ulnohumeral... (Review)
Review
BACKGROUND
Fractures of the anteromedial facet (AMF) of the coronoid process are caused by a varus posteromedial rotational injury force, leading to instability in the ulnohumeral joint. AMF fractures are usually accompanied by avulsion of the lateral ulnar collateral ligament (LUCL). O'Driscoll's description and classification of AMF coronoid fractures has increased awareness and interest in this injury, but the optimal treatment has yet to be decided.
METHODS
We systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and Embase. The primary objective was to determine outcome scores but also complication and revision rates depending on the fracture and its therapy in order to gain a more comprehensive picture. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were applied.
RESULTS
Initially, 304 publications were identified. Finally, 10 studies were left for inclusion, all of them retrospective in design, comprising 128 patients; the majority of them were male (75.7%). A total of 114 patients (89.1%) were treated surgically and 14 patients (10.9%) were treated conservatively. Among the surgically treated patients, 70.2% were treated with LUCL refixation. The average Mayo Elbow Performance Score of the surgically treated patients was 91.5 points. The average Mayo Elbow Performance Score of the conservatively treated patients was 91.4 points. A total of 10 patients (7.8%) required reoperation.
CONCLUSION
Surgery of AMF fractures leads to a satisfactory functional outcome in the vast majority of patients independent of the subtype. An algorithm for LUCL fixation is still pending. Conservative treatment may be considered under strict preconditions, especially for nondisplaced subtype 1 and 2 fractures, as these fractures show satisfactory functional outcomes when treated nonoperatively.
Topics: Collateral Ligaments; Elbow Joint; Fracture Fixation, Internal; Fractures, Bone; Humans; Range of Motion, Articular; Retrospective Studies; Treatment Outcome
PubMed: 33010433
DOI: 10.1016/j.jse.2020.09.008 -
Children (Basel, Switzerland) Aug 2023Tibial eminence fractures (TEF) of Meyers-McKeever type II-III-IV usually require surgical management. No consensus in the literature has been achieved regarding the... (Review)
Review
BACKGROUND
Tibial eminence fractures (TEF) of Meyers-McKeever type II-III-IV usually require surgical management. No consensus in the literature has been achieved regarding the best treatment option. The aims of the present systematic review were (1) to analyze the current literature and describe the outcomes of surgical treatment for TEF; and (2) to compare the outcomes of different surgical options using arthroscopic reduction and internal fixation (ARIF) with sutures or screws and open reduction and internal fixation (ORIF).
METHODS
A search was carried out with Pubmed, Medline, and Cochrane. Key terms were used "tibial" AND "eminence" or "spine" or "intercondylar" AND "paediatric" or "children" AND "fracture" or "avulsion" AND "treatment". Twelve articles met the inclusion criteria. Demographic data, clinical outcomes, and complication rates were evaluated for each study. Means/standard deviation and sum/percentage were used for continuous and categorical variables, respectively. Chi-square or t-student tests were applied. A -value < 0.05 was considered statistically significant.
RESULTS
ORIF showed superior clinical outcomes (Tegner ( < 0.05) and Lysholm ( < 0.001) scores) relative to ARIF and a lower incidence of arthrofibrosis ( < 0.05) and implant removal ( < 0.01). The Tegner, IKDC, and Lysholm scores showed statistically significant superior results following arthroscopic sutures compared to arthroscopic screws ( < 0.001). The incidence of arthrofibrosis was higher after arthroscopic sutures ( < 0.05), the implant removal was higher after screw fixation ( < 0.001) Conclusions: Better clinical results with low complication rates were achieved with ORIF surgery rather than ARIF; arthroscopic suture fixation resulted in higher clinical results compared to arthroscopic screw fixation and reduced the incidence of postoperative complications.
PubMed: 37628378
DOI: 10.3390/children10081379 -
Plastic and Reconstructive Surgery.... Jan 2020Nail bed and fingertip injuries are the commonest hand injuries in children and can lead to profound functional and cosmetic impairments if not appropriately managed.... (Review)
Review
UNLABELLED
Nail bed and fingertip injuries are the commonest hand injuries in children and can lead to profound functional and cosmetic impairments if not appropriately managed. Fingertip injuries can present with subungual hematomas, simple or stellate lacerations, crush, or avulsion injuries, often with associated fractures or tip amputations. The fundamentals of managing nail bed injuries concern restoring the form and function of a painless fingertip. However, there are controversies surrounding the optimal management of each of these injuries, which has led to nonuniformity of clinical practice.
METHODS
The PubMed database was searched from March 2001 to March 2019, using a combination of MeSH terms and keywords. Studies evaluating children (<18 years of age) and the fingertip (defined as distal to the distal interphalangeal joint) were included following screening by the authors.
RESULTS AND CONCLUSION
The evidence base for the diverse clinical management strategies currently employed for fingertip injuries in the pediatric population is limited. Further studies yielding level I data in this field are warranted.
PubMed: 32095403
DOI: 10.1097/GOX.0000000000002595