22nd European Congress of Trauma & Emergency Surgery

Chairs

Prof.

Urethral injury secondary to advanced fragility fracture of the pelvis: A case report

Abstract text (incl. references and figure legends) Case history: 83-year-old woman with no trauma history complaining acute pain in right groin was admitted to emergency room. Clinical findings: She showed swelling in her groin and urinary retention. Vital signs at admission were stable. Investigation/Results: Computed tomography (CT) showed bilateral iliac fractures with insufficient callus and right pubic ramus fracture with osteolytic lesion, which were considered advanced fragility fracture of the pelvis (FFP). It also showed a balloon of Foley catheter besides fractured pubic ramus that deviated from urethra. Enhanced CT showed accumulation of fluid with surrounding inflammation from right pubis to adductor muscles. Diagnosis: Urethral injury and groin abscess secondary to advanced FFP (Rommens classification type IVa) Therapy and Progressions: Cystostomy, puncture drainage for the groin abscess, and antibiotic administrations were performed to control the leakage of urine and the infection. At 3 weeks after admission, as the leakage and the infection had been improved, we performed internal fixations for bilateral iliac fractures to obtain enough stability for mobilization and avoiding further injury of urethra. Although she needs permanent cystostomy tube, she is able to stand alone without pain at 10 weeks after surgery. Comments: Urethral injury is common in pelvic trauma and usually occurs at the time of high energy injury. In the presented case, chronic instability of the pelvic ring, caused by progressive FFP, had resulted in the complete rupture of urethra. Bladder rupture is more common among urinary tract complications due to FFPs. This is the first report of urethral rupture secondary to advanced FFPs. References: N. V. Johnsen, et al. Epidemiology of blunt lower urinary tract trauma with and without pelvic fracture. Urology 2017;102:234-239. Y. Yamakawa, et al. Nonunion fragility fracture of the pelvis with complication from bladder rupture: A case report. Trauma Case Reports 2019;20:100169 Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Polytrauma

Skeletal trauma and sports medicine

Poster

Hoffa's fracture with patellar entrapment – A rare presentation of a rare fracture

Abstract text (incl. references and figure legends) Case History: Hoffa&quot;s fractures are defined as coronal plane fractures of the distal femur, involving the medial, lateral or both condyles. This rare type of fracture accounts for 0.65% of all femoral fractures. It usually presents in high-energy trauma – often involving other injuries or polytrauma, making its diagnosis sometimes challenging, warranting high clinical suspicion. Associated knee joint injuries include ipsilateral femur and tibial fractures, patellar dislocation and patellar fractures. CT scan is a mandatory tool for assessment of Hoffa&quot;s fractures, sometimes overlooked in X rays, and treatment planning. Clinical Findings: In this clinical case, a 19-year-old patient presented with a high energy monotrauma to the right knee. The knee was locked in 45º degrees flexion and very painful to mobilize. Local swelling, joint effusion and 1 centimetre wound were present. Results: X rays and CT scan demonstrated a lateral condyle Hoffa&quot;s fracture associated with a rare injury – inferior patellar dislocation with impaction to the femur. Wound lavage, disinfection and I.V. antibiotics were administered. The patient was taken to the OR. Intraoperatively, partial quadricipital tear was also diagnosed. Therapy and Progressions: The fracture was treated with open reduction and internal fixation using two 4,5mm cancellous screws, the patella was reduced, and quadricipital tendon was reinserted using transosseous patellar tunnels. A great functional outcome was observed post-operatively after physical therapy. The patient was discharged at 3 months with full range of motion and no pain. Comments: Hoffa&quot;s fractures treatment should be addressed with principles of articular fractures – open and anatomical reduction followed with internal stable fixation. Closed reduction of a dislocated patella with Hoffa&quot;s fracture in an emergency room and field triage is unadvised, to prevent patellar tendon incarceration, patellar tendon rupture, and osteochondral damage.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No.

Tibial and fibular refracture with intramedullary nail bending – A surgical challenge

Abstract text (incl. references and figure legends) Case History: Tibial and fibular shaft fractures are common lower limb injuries. Varied treatment strategies exist for different settings – open vs closed fractures; low vs high soft tissue injury; fracture location; concomitant injuries. However, some presentations are rarer and more challenging to treat. In this clinical case, a young male with prior history of right distal fibula and tibia shaft fractures presented in the ER, due to right leg trauma. Clinical history revealed that previous treatment was performed with tibial nailing and fibular plate with a reasonable clinical outcome. The last X ray showed good fracture alignment, albeit with delayed tibial shaft union. Clinical Findings: The patient presented with right leg deformity, swelling and pain. No wounds were present. New X rays showed refracture of distal fibula and tibia and bending of the tibial nail. Results: The patient was admitted to the hospital, and surgery was delayed to wait for soft tissue conditions and define a surgical plan. Therapy and Progressions: First, a tibial bone window was created, proximally to the nail bending site, and the nail was cut with a diamond high-speed drill. The nail was then removed, the proximal part using its extraction system, and the distal one using a clamp and hammer. Thorough endomedullary canal irrigation was performed to remove nail debris. Then, fibular osteotomy was performed to correct coronal alignment and new fixation was achieved with another tibial nail of higher diameter. After surgery, partial weightbearing and active mobilization was permitted. Excellent clinical outcome was achieved. 11 month post operative X rays showed bone consolidation with good alignment. Comments: New fractures over previously operated sites always constitute greater challenges for a trauma surgeon. This case imposed various challenges, the main one being the removal of a damaged tibial nail. Using a diamond drill to facilitate extraction constituted a viable solution.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Meyers-McKeever type 4 tibial spine avulsion – Arthroscopic reduction and fixation using tibial tunnels: A helpful technique to treat a challenging fracture

Abstract text (incl. references and figure legends) Case History: Tibial spine fractures are intra-articular fractures involving the anterior cruciate ligament (ACL) bony insertion. They occur in the paediatric population, usually 8-14 years old, typically during sports activity. Modified Meyers and McKeever Classification is often used to categorize severity and define treatment. This clinical case shows a 13-year-old male, who sustained right knee hyperextension trauma, resulting in a type 4 tibial spine avulsion. Clinical Findings: Immediate inability for weightbearing and knee effusion occurred after trauma. Marked swelling and effusion were observed, and mobilization elicited disabling pain. Joint aspiration confirmed hemarthrosis. X rays showed a tibial spine fracture. CT scan revealed a displaced, comminuted and rotated fragment – hence, a type 4 Meyers and McKeever fracture. Results: Knee arthroscopy was performed, which showed partial intermeniscal ligament injury but excluded meniscal injury. The fracture site was debrided, arthroscopic reduction was performed and provisional fixation achieved with a K wire. Pull-out technique was chosen for definitive fixation: sutures were passed through the ACL&quot; distal fibres, then two tibial tunnels were drilled – from which the sutures were passed and tied. Reduction of smaller comminuted fragments was achieved due to their common ACL ligament insertion. Therapy and Progressions: After surgery, the patient was immobilized with an extension brace for 1 week. He then went through physical therapy protocol for typical ACL surgery with gradual recovery until full return to sports at 6 months, with full range-of-motion and no pain. Comments: Surgical treatment is usually reserved for non-reduceable, displaced fractures. Arthroscopic treatment has risen in popularity due to being less invasive, providing diagnosis of associated intra-articular injuries, and various treatment options. Using the ACL as means of fracture fixation is a valid tool to treat type 4 fractures.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No.

Combination of bone transplantation and chondral repair for large traumatic osteochondral defect of the knee joint

Abstract text (incl. references and figure legends) PATIENTS AND METHODS: Case 1; 61 year old male injured open lateral condyle fracture of femur by to be bitten by a pig. After 5 months from initial debridement, I confirmed the size of bone defect was 3cm(2) X 3cm in depth. The same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. After seven months from bone transplantation, I confirmed bone union and two 6.5 mm diameter osteochondral grafts and 4.5 mm diameter osteochondral graft were transplanted for the chondral defect lesion. Case 2; seventy year old male injured open lateral condyle fracture of femur by traffic accident. After 3 months from first debridement, I confirmed the bone defect ( size 7cm(2) X 3cm in depth ) and the same size of bone was harvested from iliac crest and transplanted in the bone defect area. And simultaneously two 10 mm diameter osteochondral grafts were transplanted for the chondral defect lesion. Case 3; 37 year old male injured open lateral condyle fracture of femur by traffic accident. I confirmed the size of bone defect was 6cm(2) X 3cm in depth. The same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. After one month from bone transplantation, he had undergone ACI. RESULTS: In all cases, Lysholm knee scoring scale was good. Average follow-up period was two years and one month. Average flexion angle of knee was 147 degrees. CONCLUSION: Combination of bone transplantation and OAT or ACI is useful strategy for the large traumatic osteochondral defects of the knee joint. REFERENCES: Tegner Y., Lysholm J., Clin Orthop Relat Res., 198, 43-108, 1985Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Open lunate dislocation: A rare clinical case

Abstract text (incl. references and figure legends) Case history A 55 years old male with dyslipidemia, medicated with atorvastatin, was victim from a car crush after work, on his way home. Clinical findings The patient presented on emergency room with a large wound on wrist's volar side. Additionally, he complained about numbness on median hand"s territory. Investigation/Results Wrist X-ray and CT showed a lunate dislocation and radius styloid fracture. The patient went to operating theater and intraoperatively we found out lunate present on wound"s subcutaneous tissue. Diagnosis The diagnosis of open lunate dislocation plus radius styloid fracture was made. Therapy and Progression The patient was submitted to irrigation, debridement, open reduction and internal fixation with 4 K wires and carpal tunnel release. On immediate postoperative period patient had fingers" active mobility intact, with a normal capillary refill, without paresthesias on the thumb and improved numbness on the rest of the fingers. Patient was then transferred to insurance company hospital. The K-wires were left in place for 4 weeks and begun a rehabilitation program after that. The patient went back to our institution 8 months after surgery, lost on follow-up, complaining of wrist pain. QuickDASH score was 11. On wrist x-ray lunate was dislocated. Wrist arthrodesis was proposed to symptom relief. Although, patient refused, once his wrist mobility was vital to his labor. Comments Lunate dislocation is a rare condition related to high energy trauma events. Open lesion is even rarer and prognosis is worst. A correct diagnosis, prompt treatment and a thorough follow-up are essential to minimize complications. Despite the correct treatment, there is a high risk of further complications. References Wu X et al. Treatments for acute and old distal radius fracture with lunate dislocation. Eur J Orthop Surg Traumatol.2013.23(2):191–6 Muppavarapu R, Capo J. Perilunate Dislocationsand Fracture Dislocations. Hand Clin.2015.31(3):399-408 Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Emergency surgery

Type III tibial tuberosity avulsion fracture – A niche injury type in athletic adolescents

Abstract text (incl. references and figure legends) Case History: Tibial tuberosity fractures, or tibial tubercle fractures, amount to less than 1% of all paediatric fractures, but are common in the setting of adolescent athletic patients. Mechanisms of injury usually consist of either concentric contraction of the quadriceps while jumping, or eccentric quadriceps contraction during forced knee flexion. This is the case of a 14-year-old girl sustaining a type III tibial tuberosity fracture after a jump. Clinical Findings: Left knee effusion was evident, with associated pain and functional impotence with complete impairment of the extensor apparatus. X rays and CT scan confirmed a displaced tibial tuberosity fracture-avulsion, in the coronal plane, extending posteriorly to cross the primary ossification centre – a type 3 fracture according to modified Ogden classification. Results: Surgical treatment was performed – open reduction and internal fixation using cancellous lag screws with washers. Patellar tendon degloving was observed at its insertion site, and was repaired using 2 suture anchors. No other lesions were found. Extension splint was applied after wound closure. Therapy and Progressions: Weightbearing was not permitted until the knee splint was removed at 4 weeks post-op. Physical therapy was then instituted. At 9 months, the fracture was healed, and the patient was asymptomatic and back to sports – hardware removal was then carried out at 12 months. Comments: Prognosis of these fractures is usually good when correctly treated, with high rate of bon union and return to sports. The surgeon should be on alert for associated injuries, though, such as extensor apparatus lesions or intraarticular pathology. In around 4% of cases, compartment syndrome has been described, due to laceration of the recurrent anterior tibial artery – which did not occur in this case.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No.

Bilateral adductor canal block and sciatic nerve block for multiple fracture reduction in a patient affected by osteogenesis imperfecta: A case report

Abstract text (incl. references and figure legends) A 44 year old male affected by osteogenesis imperfecta type 3 was brought to the E.R. following an inadvertent fall from his wheelchair resulting in probable multiple closed fractures of both legs. A primary survey reported a stable patient with no apparent pelvic fracture and markedly deformed lower limbs, no compound fractures were noted. A pedideal pulse was present in both feet and no nerve damage was appreciated. The NRS 10 when moved even slightly. Past medical history included numerous fractures involving all four limbs with some requiring surgery, severe deformity of both the thorax and the thoracic spinal segments; no active medication was reported. Since the patient was stable, a CT scan of the pelvis and both legs was ordered in order to clearly diagnose the fractures (fig.1). The CT reported "displaced intercondylar fracture of the left femur, displaced fracture of the left distal tibia and fibula, a displaced fracture of the right medial tibia and fibula". A full stomach was noted on the scans. The orthopedic surgeon opted for an attempt at a non-operative reduction of both fractures. The patient refused to be undressed without first receiving deep sedation or general anesthesia. The on-call anesthesiologists were consulted. Given the high risk involved in securing the airway for general anesthesia or deep sedation, a combined approach of i.v. analgesia and light sedation (RASS-1/-2) with a peripheral nerve block was chosen. A bilateral ultrasound guided abductor canal block coupled with a bilateral sciatic nerve block was performed. Both fractures were reduced and splinted, the patient reported a NRS 1 and RASS 0. The following day a perineural catheter was placed in the right abductor canal. Only one dose of PRN rescue oral opioids was requested by the patient during his stay. We showed how non O.R. regional anesthesia can be used to perform a fracture reduction in a patient with a difficult and high risk airway and limit opioid use post procedure.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) no

Prof. Dr.

Surgical vacuum filter derived bone grafting substitute displays osteogenic microRNA and mRNA profiles

Abstract text (incl. references and figure legends) Background Autograft is the golden standard in bone reconstruction, recently a surgical vacuum filter, BoneFlo (Curasan, Germany) was introduced that provides a bone grafting substitute (BGS).The osteogenic capacity of this grafting material, however, is unclear. The aim of this study was therefore to assess the osteogenic miRNA and mRNA expression of this BGS. Methods Samples were collected during non-union surgeries. A surgical vacuum filter (BoneFlo) containing Cerasorb (Curasan, Germany) was fitted to the general surgical vacuum system as soon as the bone was exposed during the surgical procedure. For control samples, whole blood was collected from 5 healthy volunteers and combined with Cerasorb. Subsequently, all samples were snap-frozen and mechanically disrupted. MiRNAs and mRNAs were isolated, transcribed, and pooled for qPCR analysis, followed by further in silico target analyses. Results In total, samples were collected in 7 patients during non-union surgery. From the qPCR data, distinct differences in miRNA and mRNA expression were found between the surgical vacuum filter BGS and the whole blood control samples. A total of 27 miRNAs were shown to be differentially expressed in BGS as compared to the whole blood control samples. Of these 27 miRNAs, six were down, and 21 upregulated. In silico target analyses revealed 116 mRNA targets for the 27 deregulated miRNAs. Discussion This study revealed distinct osteogenic miRNA and mRNA expression profiles in surgical vacuum filter derived human BGS, linked to important processes in the fracture healing cascade and inflammatory response. Most upregulated miRNAs showed to be involved in osteoblastogenesis, mineralization, and angiogenesis. The identified miRNA profiles in the graft material were not seen in samples with whole blood only, indicating that the derived material indeed displays osteogenic properties. Lastly, early osteogenic marker gene expression was upregulated in the BGS comapred to the control. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) This study was partly sponsored by Curasan, Germany.

Intracapsular hip fractures: Experience of a single center

Abstract text (incl. references and figure legends) Introduction: Hip fractures are common among the elderly. Mortality rate (MR) can reach 30% at 1-year (1y) after surgery. Time to surgery (TS) is important to clinical outcomes and a surgery delay may lead to an increase in mortality. Methods: We did a retrospective analysis about all the patients with intracapsular fractures treated in our center between 2018 and 2021 and we collect data concerning sex, age, treatment strategy, TS, surgical approach, length of stay (LOS), pre or postoperative complications, need for blood transfusion (BT), difference between pre and postoperative hemoglobin (Hb), discharge destination (DD), and MR at 1-year after surgery. We did a statistical analysis with SPSS. The data did not follow a normal distribution. Results: We got 156 patients, 103 females and 53 males, with a median (M) age of 82 years old. 55 patients were submitted to total hip arthroplasty (THA), 90 to partial hip arthroplasty (PHA), 9 to fixation with cannulated screws, 1 to Girdlestone procedure and 1 to conservative treatment. The M LOS was 12 days, with a M TS of 3 days. 27,7% of cases were discharged to a continued care unit. The overall 1y MR was 10,9%. The age, TS, LOS and Hb difference didn&quot;t influence the 1y MR after surgery (p&gt;0,05). Besides, anticoagulants, pre and postoperative complications and DD didn&quot;t affect MR at 1-year follow-up either (p&gt;0,05). The 1y MR was different between patients submitted to THA and PHA (X2=4,30;p=0,038) - THA patients with a MR of 3,7% and PHA patients with 13,6%. 25% of the patients that received BT were dead at 1 year follow-up comparing with a MR of 4,7% in patients that didn&quot;t receive (X2=13,458; p=0,001).Patients submitted to THA were younger (M=73 years) than PHA patients (M=86 years) - p&lt;0,001 - but there was no difference regarding LOS, Hb difference, and BT needs. Conclusion: In our study PHA patients and blood transfusion were associated with a higher mortality rate at 1 year after surgery.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Periprosthetic fractures after total hip replacement

Abstract text (incl. references and figure legends) Introduction. With the increase in total hip arthroplasty and the aging of the population, complications, in particular, periprosthetic fractures, increase. These are complicated fractures that require an individual approach due to the presence of an implant and the assessment of its stability. The main goal of the treatment is to get optimal reduction of the fracture and to have functional joint without pain. The purpose of the presentation is to identify the different types of periprosthetic fractures and the individual approach to each of them. Materials and methods. We present 22 cases with 5 year follow up of periprosthetic fractures that belong to different groups of the Vancouver classification, during and after the hip replacement surgery. Various solutions are applied - plates, alloosteoplasty, stem revision, cerclage. 3 patients suffered from high energy trauma, and 19 – low energy trauma. In group with low energy trauma average age was 80, in other group- 55 Results. In the follow up we have 2 refractures due to debricolage or non-union and they had to be reoperated. 4 Patient had died in process of following up due to other illness. Conclusion. Patients have good clinical and radiological results and minimal complications. In such a complicated cases we need to choose the best method to maintain stability and secure union. In older patient with low energy trauma we discovered loosened endoprothesis. Despite relaxation of the endoprotesis some of the patient was treated with plates and cerclage due to the high risk for the patient with revision THA. Key words. Preriprosthetic fracture, Vancouver classification, reoperation, stability, THADisclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) I do not have financial interest.

Poster Session 17
Skeletal trauma and sports medicine 2

Appointment

Chairs

Programme

Poster Session 17Skeletal trauma and sports medicine 2

Appointment

Chairs

Programme

Poster Session 17
Skeletal trauma and sports medicine 2