Langer, J Orthop Trauma 2010 - The Cortical Step Sign as a Tool for Assessing and Correcting Rotational Deformity in Femoral Shaft Fractures

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The Cortical Step Sign as a Tool for Assessing and Correcting Rotational Deformity in Femoral Shaft Fractures

Langer, Ricci, et al.·J Orthop Trauma·2010·66 citations·Biomechanical study

Purpose

Rotational malalignment during femoral nailing is common. The difference in cortical width of the proximal and distal fracture fragments, the cortical step sign, is a commonly used yet poorly studied method of evaluating rotational alignment. This study aims to critically analyze the cortical step sign in cadaveric specimens using radiographic and direct measurements.

Methods

One-centimeter segments from 20 cadaveric femora were harvested from the proximal, middle, and distal diaphyses. The medial and lateral cortical widths were measured in neutral and at 10 degrees , 20 degrees , and 30 degrees of internal rotation and external rotation directly from the gross specimens and indirectly using radiographs and cross-sectional imaging.

Results

Anatomic, radiographic, and cross-sectional imaging measurements all demonstrated that cortical width changes with femoral rotation.
Rotation (both internal rotation and external rotation) of the proximal and middle segments led to a decrease in medial cortical width and lateral cortical width in 70% to 100% of samples (up to 2.2 mm, or 20% of cortical width) indicating that the cortices are thickest directly medially and laterally in neutral rotation.
In the distal femur, however, internal rotation and external rotation led to an increase in medial cortical width and lateral cortical width in 80% to 95% of cases (up to 1.75 mm), except in the case of the medial cortical width in internal rotation, which decreased in 80% of the specimens (up to 1.3 mm).

Conclusions

The cortical step sign, or incongruity of cortical widths on either side of a femur fracture, is indicative of rotational malreduction. Whether such malreduction is the result of internal rotation or external rotation, however, cannot be easily determined from this radiographic sign.

Copyright remains with the authors and publisher.

The Cortical Step Sign as a Tool for Assessing and Correcting Rotational Deformity in Femoral Shaft Fractures

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Effects of Bracing in Adolescents with Idiopathic Scoliosis.

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Adolescent Idiopathic Scoliosis: A New Classification to Determine Extent of Spinal Arthrodesis.

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Problems in the Management of Type III (Severe) Open Fractures: A New Classification of Type III Open Fractures.

Gustilo, Williams, et al.J Trauma19842,361 citationsRetrospective cohort

Neer Award 2005: The Grammont Reverse Shoulder Prosthesis: Results in Cuff Tear Arthritis, Fracture Sequelae, and Revision Arthroplasty.

Boileau, Hovorka, et al.J Shoulder Elbow Surg20061,115 citationsProspective cohort

A System for the Surgical Staging of Musculoskeletal Sarcoma.

Enneking, Goodman, et al.Clin Orthop Relat Res19802,112 citationsRetrospective cohort

Fracture Fixation in the Operative Management of Hip Fractures (FAITH): An International, Multicentre, Randomised Controlled Trial.

Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) InvestigatorsLancet2017310 citationsRCT

Fatty Muscle Degeneration in Cuff Ruptures. Pre- and Postoperative Evaluation by CT Scan.

Goutallier, Voisin, et al.Clin Orthop Relat Res19942,669 citationsProspective cohort

Dislocations after Total Hip-Replacement Arthroplasties.

Lewinnek, Zimmerman, et al.J Bone Joint Surg Am19782,549 citationsRetrospective cohort

Morphologic Study of the Glenoid in Primary Glenohumeral Osteoarthritis.

Walch, Khoury, et al.J Arthroplasty19991,142 citationsRetrospective cohort

The Three Column Spine and Its Significance in the Classification of Acute Thoracolumbar Spinal Injuries.

DenisSpine (Phila Pa 1976)19832,566 citationsRetrospective cohort

The Reverse Shoulder Prosthesis for Glenohumeral Arthritis Associated with Severe Rotator Cuff Deficiency. A Minimum Two-Year Follow-Up Study of Sixty Patients.

Frankle, Vasey, et al.J Bone Joint Surg Am2005773 citationsRetrospective cohort

Randomized Trial of Reamed and Unreamed Intramedullary Nailing of Tibial Shaft Fractures.

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A New Classification of Thoracolumbar Injuries: The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status.

Vaccaro, Oner, et al.Spine (Phila Pa 1976)2005866 citationsConsensus statement

A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds.

FLOW Investigators, Guyatt, et al.N Engl J Med2015347 citationsRCT

Curve Progression in Idiopathic Scoliosis.

Weinstein, PonsetiJ Bone Joint Surg Am1983641 citationsRetrospective cohort

Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repairs: Significance of the Inverted-Pear Glenoid and the Humeral Engaging Hill-Sachs Lesion.

Burkhart, De BeerArthroscopy20001,884 citationsCase series

The Value of the Tip-Apex Distance in Predicting Failure of Fixation of Peritrochanteric Fractures of the Hip.

Baumgaertner, Keggi, et al.J Bone Joint Surg Am19951,441 citationsRetrospective cohort

Transchondral Fractures (Osteochondritis Dissecans) of the Talus.

Berndt, HartyJ Bone Joint Surg Am1959945 citationsBiomechanical study

Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis.

Weinstein, SPORT Investigators, et al.N Engl J Med20081,207 citationsRCT

The Lateral Pillar Classification of Legg-Calvé-Perthes Disease.

Herring, Browne, et al.J Pediatr Orthop1992461 citationsRetrospective cohort

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Yamaguchi, Middleton, et al.J Shoulder Elbow Surg2001498 citationsRetrospective cohort

The Rotator Crescent and Rotator Cable: An Anatomic Description of the Shoulder's "Suspension Bridge".

Burkhart, Jolson, et al.Arthroscopy1993469 citationsAnatomic study

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O'Driscoll, Morrey, et al.J Bone Joint Surg Am1991997 citationsCase series

Preoperative versus Postoperative Radiotherapy in Soft-Tissue Sarcoma of the Limbs: A Randomised Trial.

O'Sullivan, Zee, et al.Lancet20021,587 citationsRCT

Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures. A Multicenter, Randomized Clinical Trial.

Canadian Orthopaedic Trauma SocietyJ Bone Joint Surg Am2007804 citationsRCT

Microvasculature of the Human Meniscus.

Arnoczky, WarrenAm J Sports Med19821,227 citationsAnatomic study

Metastatic Disease in Long Bones. A Proposed Scoring System for Diagnosing Impending Pathologic Fractures.

MirelsClin Orthop Relat Res19891,222 citationsRetrospective cohort

Early versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS).

Fehlings, Rampersaud, et al.PLoS One20121,200 citationsProspective cohort

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NeerClin Orthop Relat Res19831,827 citationsReview article

Direct Decompressive Surgical Resection in the Treatment of Spinal Cord Compression Caused by Metastatic Cancer: A Randomised Trial.

Patchell, Young, et al.Lancet20052,356 citationsRCT

Injuries Involving the Epiphyseal Plate

Salter, HarrisJ Bone Joint Surg Am19631,737 citationsRetrospective cohort

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Burkhart, Kibler, et al.Arthroscopy2003929 citations

Cuff-Tear Arthropathy.

Neer, Fukuda, et al.J Bone Joint Surg Am1983774 citationsCase series

A System of Staging Musculoskeletal Neoplasms.

EnnekingClin Orthop Relat Res19861,083 citationsReview article

Elbow Instability.

O'DriscollActa Orthop Belg199959 citationsReview article

Effect of Achilles Tendon Lengthening on Neuropathic Plantar Ulcers: A Randomized Clinical Trial

Mueller, Johnson, et al.J Bone Joint Surg Am2003347 citationsRCT

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HarringtonJ Bone Joint Surg Am1981303 citationsCase series

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Beck, Ganz, et al.J Bone Joint Surg Br20051,955 citationsRetrospective cohort

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Sanders, Walling, et al.Clin Orthop Relat Res1993891 citationsProspective cohort

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Stulberg, Wallensten, et al.J Bone Joint Surg Am1981810 citationsRetrospective cohort

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Jobe, Lombardo, et al.J Bone Joint Surg Am1986758 citationsCase series

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NeerJ Bone Joint Surg Am1974598 citationsCase series

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HawkinsJ Bone Joint Surg Am1970556 citationsRetrospective cohort

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CharnleyLancet1961834 citationsCase series

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Grood, Noyes, et al.J Bone Joint Surg Am1988674 citationsBiomechanical study

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NeerJ Bone Joint Surg Am19701,957 citationsRetrospective cohort

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Stiell, Worthington, et al.JAMA20011,283 citationsProspective cohort

The Arterial Vascularization of the Humeral Head. An Anatomical Study.

Gerber, Vinh, et al.J Bone Joint Surg Am1990441 citationsAnatomic study

SLAP Lesions of the Shoulder.

Snyder, Friedman, et al.Arthroscopy19901,264 citationsCase series

Displaced Proximal Humeral Fractures. II. Treatment of Three-Part and Four-Part Displacement.

NeerJ Bone Joint Surg Am19701,283 citationsRetrospective cohort

Functional and Structural Outcome after Arthroscopic Full-Thickness Rotator Cuff Repair: Single-Row versus Dual-Row Fixation

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Rosenberg, Wesley, et al.Ann Surg19821,347 citationsRCT

Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder. 1972.

NeerJ Bone Joint Surg Am1972536 citationsCase series

Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects. A Prospective Investigation.

Boden, Wiesel, et al.J Bone Joint Surg Am1990668 citationsProspective cohort

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Griffin, FASHIoN Study Group, et al.Lancet2018542 citationsRCT

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Insall, Burstein, et al.J Bone Joint Surg Am1982470 citationsRetrospective cohort

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Brooker, Riley, et al.J Bone Joint Surg Am19732,880 citationsRetrospective cohort

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Dejour, Guier, et al.Knee Surg Sports Traumatol Arthrosc19941,987 citationsCase-control study

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Morrey, Chao, et al.J Bone Joint Surg Am19811,380 citationsBiomechanical study

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Burkhart, Kibler, et al.Arthroscopy20031,304 citationsReview article

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Boileau, Balg, et al.J Shoulder Elbow Surg20051,232 citationsReview article

Fractures of the Acetabulum: Classification and Surgical Approaches for Open Reduction. Preliminary Report.

Judet, Letournel, et al.J Bone Joint Surg Am1964980 citationsCase series

Inferior Capsular Shift for Involuntary Inferior and Multidirectional Instability of the Shoulder. A Preliminary Report.

Neer, FosterJ Bone Joint Surg Am1980934 citationsCase series

The Impact of Positive Sagittal Balance in Adult Spinal Deformity.

Glassman, Schwab, et al.Spine (Phila Pa 1976)20051,878 citationsRetrospective cohort

An Analysis of Outcomes of Reconstruction or Amputation after Leg-Threatening Injuries.

Bosse, Castillo, et al.N Engl J Med2002901 citationsProspective cohort

Normal and Abnormal Motion of the Shoulder.

Poppen, WalkerJ Bone Joint Surg Am1976886 citationsCase-control study

Posterior C1-C2 Fusion with Polyaxial Screw and Rod Fixation.

Harms, MelcherSpine (Phila Pa 1976)20011,528 citationsCase series

A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures.

Kallmes, Jarvik, et al.N Engl J Med20091,422 citationsRCT

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Buchbinder, Murphy, et al.N Engl J Med20091,416 citationsRCT

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Hoffman, Zucker, et al.N Engl J Med20001,302 citationsProspective cohort

Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture

HEALTH Investigators, Devereaux, et al.N Engl J Med2019507 citationsRCT

A Classification for Congenital Limb Malformations.

SwansonJ Hand Surg Am1976429 citationsReview article

Treatment of Grade IV Fracture-Dislocation of the Hip.

PipkinJ Bone Joint Surg Am1957445 citationsCase series

Compression-Plate Fixation in Acute Diaphyseal Fractures of the Radius and Ulna

Anderson, Park, et al.J Bone Joint Surg Am1975416 citationsCase series

Legg-Calve-Perthes Disease. Part II: Prospective Multicenter Study of the Effect of Treatment on Outcome.

Herring, Browne, et al.J Bone Joint Surg Am2004143 citationsProspective cohort

The Role of the Scapula in Athletic Shoulder Function.

KiblerAm J Sports Med19981,240 citationsReview article

The SLAC Wrist: Scapholunate Advanced Collapse Pattern of Degenerative Arthritis.

Watson, BalletJ Hand Surg Am19841,138 citationsRetrospective cohort

Classification and an Algorithmic Approach to the Reconstruction of Femoral Deficiency in Revision Total Hip Arthroplasty.

Valle, PaproskyJ Bone Joint Surg Am2003199 citationsRetrospective cohort

The Tibial Plateau Fracture. The Toronto Experience 1968--1975.

Schatzker, Bruce, et al.Clin Orthop Relat Res19791,029 citationsRetrospective cohort

Surgical Dislocation of the Adult Hip a Technique with Full Access to the Femoral Head and Acetabulum without the Risk of Avascular Necrosis.

Ganz, Berlemann, et al.J Bone Joint Surg Br20011,367 citationsCase series

Predictors of Humeral Head Ischemia after Intracapsular Fracture of the Proximal Humerus.

Hertel, Leunig, et al.J Shoulder Elbow Surg2004837 citationsProspective cohort

Early versus Delayed Stabilization of Femoral Fractures. A Prospective Randomized Study.

Bone, Scheinberg, et al.J Bone Joint Surg Am1989795 citationsRCT

Acetabulum Fractures: Classification and Management.

LetournelClin Orthop Relat Res1980715 citationsRetrospective cohort

A Novel Classification System for Spinal Instability in Neoplastic Disease: An Evidence-Based Approach and Expert Consensus from the Spine Oncology Study Group.

Fisher, Fourney, et al.Spine (Phila Pa 1976)20101,224 citationsConsensus statement

Surgical vs. Nonsurgical Treatment of Adults with Displaced Fractures of the Proximal Humerus: The PROFHER Randomized Clinical Trial.

Rangan, PROFHER Trial Collaborators, et al.JAMA2015540 citationsRCT

Lumbar Disc Herniation. A Controlled, Prospective Study with Ten Years of Observation.

WeberSpine (Phila Pa 1976)19831,149 citationsRCT

Surgical vs. Nonoperative Treatment for Lumbar Disk Herniation. The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial

Weinstein, Deyo, et al.JAMA20061,086 citationsRCT

Health and Function of Patients with Untreated Idiopathic Scoliosis: A 50-Year Natural History Study.

Weinstein, Ponseti, et al.JAMA2003755 citationsProspective cohort

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The Cortical Step Sign as a Tool for Assessing and Correcting Rotational Deformity in Femoral Shaft Fractures

Langer, Ricci, et al.·J Orthop Trauma·2010·66 citations·Biomechanical study

Purpose

Rotational malalignment during femoral nailing is common. The difference in cortical width of the proximal and distal fracture fragments, the cortical step sign, is a commonly used yet poorly studied method of evaluating rotational alignment. This study aims to critically analyze the cortical step sign in cadaveric specimens using radiographic and direct measurements.

Methods

One-centimeter segments from 20 cadaveric femora were harvested from the proximal, middle, and distal diaphyses. The medial and lateral cortical widths were measured in neutral and at 10 degrees , 20 degrees , and 30 degrees of internal rotation and external rotation directly from the gross specimens and indirectly using radiographs and cross-sectional imaging.

Results

Anatomic, radiographic, and cross-sectional imaging measurements all demonstrated that cortical width changes with femoral rotation.
Rotation (both internal rotation and external rotation) of the proximal and middle segments led to a decrease in medial cortical width and lateral cortical width in 70% to 100% of samples (up to 2.2 mm, or 20% of cortical width) indicating that the cortices are thickest directly medially and laterally in neutral rotation.
In the distal femur, however, internal rotation and external rotation led to an increase in medial cortical width and lateral cortical width in 80% to 95% of cases (up to 1.75 mm), except in the case of the medial cortical width in internal rotation, which decreased in 80% of the specimens (up to 1.3 mm).

Conclusions

The cortical step sign, or incongruity of cortical widths on either side of a femur fracture, is indicative of rotational malreduction. Whether such malreduction is the result of internal rotation or external rotation, however, cannot be easily determined from this radiographic sign.

Copyright remains with the authors and publisher.

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