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Trauma: L. Cutler, A. Molloy, V. Dhukuram, and A. Bass Do CT scans aid assessment of distal tibial physeal fractures? J Bone Joint Surg Br 2004; 86-B: 239-243 [Abstract] [PDF]

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Letter from Mr A J Bing

Andrew J Bing, Michael R Carmont, Paula J Richards, John SM Dwyer   (6 January 2005)

Letter from Mr A J Bing 6 January 2005
Andrew J Bing, SpR Trauma and Orthopaedics University Hospital of North Staffordshire, Michael R Carmont, Paula J Richards, John SM Dwyer Send letter to journal: Re: Letter from Mr A J Bing ajf{at}bing700.fsnet.co.uk Andrew J Bing, et al.	Sir, We read with considerable interest the paper by Cutler et al in the March 2004 issue entitled ‘Do CT scans aid assessment of distal tibial physeal fractures?’1 and we would like to thank the authors for their excellent research in the management of these relatively common paediatric injuries. They recommend that CT scans are routinely used in the preoperative assessment and treatment of distal tibial physeal fractures, suggesting that a preoperative axial CT slice allows accurate orientation of a percutaneous screw perpendicular to the plane of the fracture, thus improving anatomical fracture reduction. It is suggested in standard orthopaedic textbooks that displaced physeal injuries be reduced as soon as possible following injury2. Delays may prevent anatomical reduction of the fracture due to interposition of organised haematoma and will allow swelling to develop thus distorting surface anatomy making percutaneous screw positioning difficult. Most DGHs now have CT scanners but urgent scans of appendicular trauma may not be obtainable 24 hours a day thus causing delay. An alternative simple technical tip is to rotate an image intensifier beam or the limb so that the fracture is clearly displayed. The long axis of the beam will then be parallel to the fracture plane, allowing a percutaneous screw to be placed perpendicular to the axis of the beam and thus the fracture. We appreciate that interposed periosteum may have to be removed from the fracture site to permit reduction. An axial image, which as suggested is often the most useful in screw positioning, is not obtainable in theatre with the image intensifier. A final consideration is the relative dose of radiation required for CT scans as compared to using an image intensifier. The newer multislice and spiral CT scanners use less radiation than conventional CTs however, as long as the field of view is not increased3 and they produce excellent multiplanar reconstructions. In their paper the authors analysed 62 patients with physeal injuries; the majority of these (87%) were uniplanar for which the image intensifier technique may suffice. The more complex triplanar injuries are more likely to require CT assessment to assist in their management. A. J. Bing, SpR Trauma and Orthopaedics University Hospital of North Staffordshire, Stoke-on-Trent, UK. 1. Cutler L, Molloy A, Dhukuram V, Bass A. Do CT scans aid assessment of distal tibial physeal fractures? J Bone Joint Surg [Br] 2004;86-B:239-43. 2.Solomon L, Warwick DJ, Nayagam S. Apley’s system of orthopaedics and fractures. Eighth edition. London: Arnold, 2001:579 3.Van der Molen AJ, Geleijns J. Quantification of overscanning and relative contribution to scan length and effective dose in 16-slice multislice CT. Scientific session 12, General and Emergency Radiology. AJR, 2004;(supp 104) 182:4:27