Case Reports in Orthopedics

Introduction. Wakeboarding is an extreme sport that has shown increasing popularity in recent years, with an estimated 2.9 million participants in 2017. Due to this trend, injuries related to this sport are likely to become more common. Isolated femoral shaft are rare; however, they occur much more frequently in youth as a result of high velocity events, such as dashboard-related injuries. Few studies have addressed injuries related to wakeboarding, and of those that have, most have reported on muscle injuries, ligament ruptures, and sprains. Due to the dearth in literature, we want to present two cases of isolated noncontact femoral shaft fractures that resulted from wakeboarding. Case Presentation. Two 28-year-old, otherwise healthy, wakeboarders—patient A, male, and patient B, female—presented to our Department of Orthopaedics and Sports Medicine with isolated femoral shaft fractures. Both were admitted due to wakeboard-related noncontact injuries, where patient A fell while performing a sit-down start during cable wakeboarding and patient B after attempting a wake-jump. Both patients were being pulled by motorboats at roughly 40 km/h. After clinical examination and radiography, left spiral (AO classification: 32-A1.2) (patient A) and right-sided bending, wedge (AO classification 32-B2.2) (patient B) isolated femoral shaft fractures were diagnosed. No concomitant injuries were reported. For treatment, long reamed locked nails were applied, while the patients were under spinal anaesthesia. Physiotherapy was prescribed postoperatively. Patient A returned to wakeboarding 155 days after the surgery, and patient B returned after approximately half a year. Conclusion. This case series shows that even in noncontact sports such as wakeboarding, high-energy forces applied to the femur can cause isolated femoral shaft fractures. Despite multiple reports in various sports of stress fractures of the femur, there are few publications of direct trauma.

Lomentospora prolificans is an emerging pathogen that is difficult to treat due to its intrinsic resistance to currently available antifungal agents. Current evidence demonstrates synergy between Azoles and Terbinafine against L. prolificans infections, while adjunct use of antifungal agent-loaded bone cement has also shown favourable outcomes. We report a case of an immunosuppressed adult with rheumatoid arthritis who developed L. prolificans osteomyelitis in his right wrist following trauma and subsequent exposure to commercially available fertiliser. The infection was successfully eradicated via a combination of aggressive, staged surgical source control, antifungal therapy using voriconazole and Terbinafine, and insertion of voriconazole-loaded bone cement into the wrist and carpus. The utility of this approach supports the synergistic effects of voriconazole and Terbinafine and, more broadly, the clinical benefits of antifungal-loaded bone cement, as demonstrated in previous case reports and in vitro studies. As such, combination antifungal therapy and voriconazole-loaded bone cement should be considered the therapy of choice in cases of osteomyelitis where L. prolificans is proven to be the causative organism.

Introduction. Peripheral nerve injury is a well-known surgical complication related to the position of the patient. Moreover, in spine surgery, prone position for prolonged period places the patient at increased risk. The aim of this study was to report a case of a radial nerve neuropraxis due to compression by C-arm fluoroscopy during spine surgery. Case Presentation. An 81-year-old-female underwent a posterior spinal fixation L2-S1 due to lumbar spinal stenosis. In the recovery room, she presented an hematoma at the posterolateral part of her arm associated with a wrist drop due to radial nerve neuropraxis. The patient was referred to an occupational therapist and fully recovered four months later. After analysis of the patient positioning during the intervention, we came to the conclusion that this radial nerve injury was very possibly due to a compression by the C-arm fluoroscopy during the surgery. Conclusion. Our case describes a rare case of compression of the radial nerve during lumbar spine surgery, which is an unexpected complication as the site of the nerve injury is not at all related to the surgery itself, but to the position of the patient. Although C-arm fluoroscopy is essential, spine surgeons should be aware of this possible complication related to its use in order to avoid it.

Accessory soleus muscle (ASM) is a rare supernumerary anatomical variant that commonly presents as a posteromedial ankle swelling, which may become painful during physical activity. As it may mimic a soft tissue tumor, it is essential to differentiate this condition from ganglion, lipoma, hemangioma, synovioma, and sarcoma. However, ASM may also present with a painful syndrome, characterized by pain and paresthesia of the ankle and foot, mimicking the tarsal tunnel syndrome (TTS). Two cases of ASM are presented in this article. The first case had a typical presentation with painful posteromedial ankle swelling. After the initial assessment, the diagnosis was confirmed by magnetic resonance imaging (MRI), and ASM was treated by complete resection. The second case presented with pain and paresthesia in the right ankle and foot, but no swelling was noticeable. It was initially misdiagnosed by a rheumatologist and afterward overlooked on an MRI by a musculoskeletal radiology specialist and therefore mistreated by numerous physicians before being referred to our outpatient clinic. After further assessment, the diagnosis has been confirmed, and ASM was treated by complete resection combined with tarsal tunnel decompression. To the best of our knowledge, this is the first case reported in which ASM caused symptoms but presented without posteromedial swelling. This might be due to a proximally positioned belly of the ASM, followed by a tendinous insertion on the medial side of the calcaneus.

Introduction. Spinal mobile tumors are very rare. We herein report a case of paraplegia caused by migration and incarceration of thoracic mobile schwannoma after myelography. Case Presentation. A 25-year-old man who had weakness and numbness in both his legs also had pain radiating to the back that was induced by back flexion or extension and jumping. Magnetic resonance imaging (MRI) showed an intradural extramedullary lesion at the T10 and T11 levels. Myelography was performed but discontinued due to his back and lower limb pain. Computed tomography after myelography revealed a rostrally migrated intradural mass with a discrepancy in the exact location in comparison to the MRI findings. He underwent a second lumbar puncture and drained the cerebrospinal fluid (CSF) to aid the spinal cord, because the symptoms gradually worsened and led to paraplegia. After the drainage of the CSF, his symptoms were immediately resolved. The day after myelography, he underwent complete resection of the tumor with the diagnosis of schwannoma. One year after the surgery, he had been working despite having hyperreflexia in his lower limbs with no weakness or sensory disturbance. Conclusion. Severe neurological deficits associated with spinal cord damage can occur due to migration of mobile tumors.

Introduction. An arachnoid web (AW) is a relatively rare disease and shows clinical symptoms and radiological findings similar to those of an arachnoid cyst (AC) or spinal cord herniation (SCH). Since the operative procedures for an AW are generally different from those intrathecal disorders, correct preoperative differential diagnosis is important. The purposes of this study were to report the usefulness of magnetic resonance imaging (MRI) and computed tomography (CT) myelography for diagnosing AW and to show the histological findings and clinical results. Case Description. Two patients, a 79-year-old man and a 43-year-old woman, are presented. The primary diagnoses were AC with ossification of the ligamentum flavum and epidural hematoma, respectively, in previous hospitals. They were finally diagnosed by the characteristic MRI and CT myelogram finding called the “scalpel sign.” Histological findings showed epithelial cells and fibrous tissue derived from arachnoid tissues and microcalcifications. After surgery, the scalpel sign has vanished, and aggravation of their symptoms was prevented. Conclusion. An AW is refractory, but early detection by MRI and CT myelography and early treatment improve outcomes after surgery.