Treated conservatively, hyperextension injuries of the cervical spine have a poor outcome, but surgical treatment does not yet provide a realistic alternative. This study was prompted by the lack of classifications of cervical spondylosis and outcome studies of hyperextension in the literature, and the absence of a user-friendly neurological score. The retrospective study included 60 patients admitted over the last 12 years with hyperextension injuries and varying degrees of neurological deficit. The mean age of patients was 52 years and most had radiological evidence of cervical spondylosis. None had any neurological deficit before the accident. Injuries were sustained in falls in 56%, in motor vehicle accidents in 34%, in assaults in 8% and in sports injuries in 2%. The neurological deficits varied: 11% had complete lesions, 33% central cord syndrome, 18% motor complete-sensory incomplete, 33% motor incomplete-sensory incomplete. The nervous system was normal in 2%. The posterior columns were often involved, with loss of pro-prioception. In the majority of cases conservative treatment consisted of six weeks of light traction in gentle flexion, followed by mobilisation in an ABCO brace for six weeks. The results showed that the mean Asia score gain for the group treated conservatively was 23, for the surgically stabilised group 3 and the surgically- decompressed group 55. There was a 16% mortality rate. The mean time for rehabilitation was 5.5 months. Both the final outcome and the time to rehabilitation were extremely variable. We present a classification of cervical spondylosis and ways of measuring congenital and acquired spinal cord narrowing. We combine the Asia and Frankel scoring systems to give a user-friendly guide

1. The literature on hyperextension injuries of the spine is briefly reviewed. 2. Such injuries in the cervical spine can be subdivided into five groups based on the pathological anatomy, based on the experience of fifty-one patients in the Spinal Injuries Centre for Victoria over the past five years. 3. Extension injuries of the thoraco-lumbar spine are discussed. They are rare and have a poor prognosis. 4. The importance of treatment based on sound clinical and pathological knowledge is emphasised, particularly in order that stable and unstable lesions may be recognised early and managed correctly

Study design: Retrospective, descriptive study. Objectives: To describe the characteristics and outcomes of patients with spinal canal stenosis who suffer significant spinal cord injury (SCI) due to hyperextension injury of the cervical spine. To compare their characteristics and outcomes with all patients suffering traumatic cervical SCI and with the total cohort of patients admitted to a Spinal Injuries Unit for rehabilitation. Setting: Spinal Injuries Unit (SIU), Princess Alexandra Hospital, Brisbane. Methods: Demographic, injury and outcome data were obtained from an existing database and by review of the medical records of 575 patients admitted to and discharged from the SIU between July 1st, 1995 and July 1st 2002. Main outcome measures were: change in American Spinal Injury Association (ASIA) scale category, change in ASIA motor score, discharge Functional Independence Measure (FIM) score and change in FIM score, length of stay (LOS), primary means of mobility at discharge and discharge destination. Standard statistical methods were used to compare groups. Results: A total of 18 (3%) of the 575 patients were found to have cervical canal stenosis and hyperextension injury (the CCS/HI group). This represents 8% of the total group suffering traumatic injury to the cervical spinal cord (the total cervical trauma: TCT group, n = 225). This CCS/HI group was found to have a mean age at injury of 55.1 years compared to 37.1 and 37.8 years respectively for the TCT and total groups. Ninety-four percent of patients were found to have a neurological level at admission at C1–3 or C4–5 compared to 75.6% of the TCT group and only 5.6% of patients had an ASIA Impairment Category A lesion at admission compared to 38.7% of the TCT group. Falls (55.6%) was the most common cause of injury in the CCS/HI group with motor vehicle accidents (33.8%) most common in the TCT group. The mean change in ASIA motor score between admission and discharge was 34.7 compared to 20.4 for the TCT group. Degree of impairment (measured by a change in ASIA Category) improved in 28% of patients and mean change in total FIM score was 41.3. There was no difference seen with the TCT group. LOS was shorter for these patients (111.1 days vs. 161.6 days). The primary means of mobility at discharge was “walking” for 50% of this group (compared to 28.4% for the TCT group) while the next most common means of mobility was “power wheelchair” at 28% (17% of TCT group). Most patients (55.4%) were discharged to their previous home following rehabilitation and 22.3% were discharged to another rehabilitation unit or acute hospital. Conclusions: Patients with cervical spinal canal stenosis who suffer hyperextension injury constitute a distinct subgroup with the total group of traumatic cervical spinal cord injuries. This study suggests that they are older at the time of injury, have more rostral cervical injuries, are more likely to have incomplete injuries and that falls is the most common cause of injury. They have greater improvement in motor function but this does not appear to result in greater function at discharge as measured by the FIM. There appears to be a dichotomy with results for mobility at discharge with patients either being able to walk or requiring a power wheelchair. LOS in the SIU is shorter but a higher percentage are discharged to another hospital or rehabilitation unit

STUDY DESIGN: Retrospective, descriptive study. OBJECTIVES: To describe the characteristics and outcomes of patients with spinal canal stenosis who suffer significant spinal cord injury (SCI) due to hyperextension injury of the cervical spine. To compare their characteristics and outcomes with all patients suffering traumatic cervical SCI and with the total cohort of patients admitted to a Spinal Injuries Unit for rehabilitation. SETTING: Spinal Injuries Unit (SIU), Princess Alexandra Hospital, Brisbane. METHODS: Demographic, injury and outcome data were obtained from an existing database and by review of the medical records of 575 patients admitted to and discharged from the SIU between July 1st, 1995 and July 1st 2002. Main outcome measures were: change in American Spinal Injury Association (ASIA) scale category, change in ASIA motor score, discharge Functional Independence Measure (FIM) score and change in FIM score, length of stay (LOS), primary means of mobility at discharge and discharge destination. Standard statistical methods were used to compare groups. RESULTS: A total of 18 (3%) of the 575 patients were found to have cervical canal stenosis and hyperextension injury (the CCS/HI group). This represents 8% of the total group suffering traumatic injury to the cervical spinal cord (the total cervical trauma: TCT group, n = 225). This CCS/HI group was found to have a mean age at injury of 55.1 years compared to 37.1 and 37.8 years respectively for the TCT and total groups. Ninety-four percent of patients were found to have a neurological level at admission at C1-3 or C4-5 compared to 75.6% of the TCT group and only 5.6% of patients had an ASIA Impairment Category A lesion at admission compared to 38.7% of the TCT group. Falls (55.6%) was the most common cause of injury in the CCS/HI group with motor vehicle accidents (33.8%) most common in the TCT group. The mean change in ASIA motor score between admission and discharge was 34.7 compared to 20.4 for the TCT group. Degree of impairment (measured by a change in ASIA Category) improved in 28% of patients and mean change in total FIM score was 41.3. There was no difference seen with the TCT group. LOS was shorter for these patients (111.1 days vs. 161.6 days). The primary means of mobility at discharge was “walking” for 50% of this group (compared to 28.4% for the TCT group) while the next most common means of mobility was “power wheelchair” at 28% (17% of TCT group). Most patients (55.4%) were discharged to their previous home following rehabilitation and 22.3% were discharged to another rehabilitation unit or acute hospital. CONCLUSIONS: Patients with cervical spinal canal stenosis who suffer hyperextension injury constitute a distinct subgroup with the total group of traumatic cervical spinal cord injuries. This study suggests that they are older at the time of injury, have more rostral cervical injuries, are more likely to have incomplete injuries and that falls is the most common cause of injury. They have greater improvement in motor function but this does not appear to result in greater function at discharge as measured by the FIM. There appears to be a dichotomy with results for mobility at discharge with patients either being able to walk or requiring a power wheelchair. LOS in the SIU is shorter but a higher percentage are discharged to another hospital or rehabilitation unit

Ankylosing spondylitis (AS) is a progressive multisystem chronic inflammatory disorder. The hallmark of this pathological process is a progressive fusion of the zygapophyseal joints and disc spaces of the axial skeleton, leading to a rigid kyphotic deformity and positive sagittal balance. The ankylosed spine is unable to accommodate normal mechanical forces, rendering it brittle and susceptible to injury. Traumatic hyperextension injury of the cervical spine leading to atlantoaxial subluxation (AAS) in AS patients can often be fatal. We report a non-traumatic mechanism of injury in AS progressing to AAS attributable to persistent hyperextension, which resulted in fatal migration of C2 through the foramen magnum. Cite this article: Bone Joint J 2013;95-B:206–9

1. The clinical and post-mortem findings are described of a patient who sustained a hyperextension injury of the neck with paraplegia. 2. There was no radiological evidence of fracture: osteoarthritis of the spine was present. 3. Evidence is presented that the cord was damaged from behind by the lamina of the vertebra below a tear in the anterior longitudinal ligament

1. The literature on paraplegia complicating hyperextension injuries of the cervical spine is reviewed, and the lack of any definite explanation of the mode of interference with cord function is noted. 2. A case is described in which a detailed dissection of the post-mortem specimen was carried out. On the basis of the findings it is suggested that one cause of the suppression of cord function in such injuries is thrombosis of the spinal arteries and liquefaction-necrosis of the cord

Introduction: Neck hyperextension (NH) is defined as a progressive increase of lordosis associated with a limitation in flexion of the cervical spine, which ultimately results in an inability to approximate the chin to the sternum. NH may occur in relation to several myopathies. It is characterized by a general weakness and contractures of the axial muscles which produces a progressive increase of lordosis associated with a limitation in flexion of the cervical spine, that forces the patient to assume awkward compensatory postures to maintain balance and level vision. This study reports on operative complications, the degree of correction, the achievement of a solid arthrodesis, the maintenance of the correction and the clinical assessment of 7 patients. Material and methods: Seven patients affected by various myophaties and NH were included. The mean age was 16.5 years (10–28 years). All underwent surgery, in which the paravertebral muscles were detached from the spinous processes and then transversally sectioned in order to bilaterally expose the laminas of vertebrae C2 to C7. The space between C1–C2 appeared mobile, while the spinous processes from C2 to C7 were close together and thus allowed only a very limited motion in between them. Ligamenti interspinosus and nuchae were detached and the facet joints from C2 to C7 were enlarged by capsulotomy. With a spreader rongeur, the interspinous spaces at each level were gently opened. Cortical cancellous autologue graft were shaped into wedges. After careful opening of each interspinous space, the bone wedges were driven between the spinous processes to maintain the achieved correction. The average follow-up time was 10.4 years (2.4–16.5 years). Results: No major surgical complications occurred. At follow-up, the average angle between C2–C7 in neutral position had decreased (p = 0.016) from 50.7 (40–70) to 21.4 (2–50). The range of motion in the C1–C2 joint remained unaffected, while it decreased in C2–C7 (p = 0.016) from 33.5 (15–64) to 1.8 (0–8). In all cases, a solid arthrodesis was achieved. Discussion and conclusion: The follow-up showed significant clinical improvement of posture in all patients. Our study has shown surgical treatment of NH to be an effective method within the whole series of seven patients, achieving both good immediate and good long-term results

1) A case is reported of paraplegia with normal radiographic appearances in which cervical cord damage was shown at autopsy to have been due to hyperextension injury. 2) The mechanism of such injuries is discussed, together with the differential diagnosis from acute prolapse of an intervertebral disc. 3) The grave dangers of using the fully extended position of the cervical spine in the management of these cases is noted

Proximal tibial epiphyseal injuries are rare. Reported incidence varies from 0.5 – 3% of epiphyseal injuries. Proximal tibial epiphysis is well protected unlike distal femoral epiphysis. Thus, the distal femoral injuries are 7 times more frequent than proximal tibial epiphyseal injuries.

Case Report: 12-year old boy, hit a pole at the bottom of a dry ski slope and presented to A& E within 20 minutes. He had a swollen, deformed knee and leg that was immobilised in a temporary splint. He had absent posterior tibial and dorsalis pedis pulses. Emergency manipulation under GA and further stabilised with K-wires, A/K Back Slab in 450 flexion. Distal pulses returned on table. K-wires were removed after 4 weeks and physiotherapy started. At 3 months, he was back to normal activities except sports. At 2 years, he was longer by 1 cm in left tibia, valgus of 120 at the knee, full ROM, no ligament laxity and reports occasional anterior knee pain.

Discussion: Posteriorly displaced proximal tibial Salter Harris II injuries are very rare. Emergency reduction and stabilisation, absence of popliteal artery tear had prevented the immediate complications. The late complications did not warrant a surgical intervention.

Aims. The paediatric trigger thumb is a distinct clinical entity with unique anatomical abnormalities. The aim of this study was to present the long-term outcomes of A1 pulley release in idiopathic paediatric trigger thumbs based on established patient-reported outcome measures. Methods. This study was a cross-sectional, questionnaire-based study conducted at a tertiary care orthopaedic centre. All cases of idiopathic paediatric trigger thumbs which underwent A1 pulley release between 2004 and 2011 and had a minimum follow-up period of ten years were included in the study. The abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH) was administered as an online survey, and ipsi- and contralateral thumb motion was assessed. Results. A total of 67 patients completed the survey, of whom 63 (94%) had full interphalangeal joint extension or hyperextension. Severe metacarpophalangeal joint hyperextension (> 40°) was documented in 15 cases (22%). The median QuickDASH score was 0 (0 to 61), indicating excellent function at a median follow-up of 15 years (10 to 19). Overall satisfaction was high, with 56 patients (84%) reporting the maximal satisfaction score of 5. Among 37 patients who underwent surgery at age ≤ two years, 34 (92%) reported the largest satisfaction, whereas this was the case for 22 of 30 patients (73%) with surgery at aged > two years (p = 0.053). Notta’s nodule resolved in 49 patients (73%) at final follow-up. No residual triggering or revision surgery was observed. Conclusion. Surgical release of A1 pulley in paediatric trigger thumb is an acceptable procedure with excellent functional long-term outcomes. There was a trend towards higher satisfaction with earlier surgery among the patients. Cite this article: Bone Jt Open 2024;5(9):736–741

Aims. Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on. Methods. Outcome of hip-preserving head reduction osteotomy combined with periacetabular osteotomy was good in one and moderate in the other up to three years after surgery; based on the pronounced hip destruction, the third received initially a total hip arthroplasty. Results. The described pathology is quite devastating, and extensive joint preserving surgery (which has been shown successful in Perthes’ cases) was less successful in this patient cohort. Conclusion. Supraselective angiography may be helpful to improve pathomechanical understanding and surgical decision making. Cite this article: Bone Jt Open 2022;3(9):666–673

Aims. Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age. Methods. Patients aged ≥ 18 years with a traumatic CCS between January 2012 and December 2017 in Wales were identified. Patient demographics and data about injury, management, and outcome were collected. Statistical analysis was performed to assess mortality and between-group differences. Results. A total of 65 patients were identified (66.2% male (n = 43), mean age 63.9 years (SD 15.9)). At a minimum of five years’ follow-up, 32.3% of CCS patients (n = 21) had died, of whom six (9.2%) had died within 31 days of their injury. Overall, 69.2% of patients (n = 45) had been managed conservatively. There was no significant difference in age between conservatively and surgically managed patients (p = 0.062). Kaplan-Meier analysis revealed no significant difference in mortality between patients managed conservatively and those managed surgically (p = 0.819). However, there was a significant difference in mortality between the different age groups (< 50 years vs 50 to 70 years vs > 70 years; p = 0.001). At five years’ follow-up, 55.6% of the patient group aged > 70 years at time of injury had died (n = 15). Respiratory failure was the most common cause of death (n = 9; 42.9%). Conclusion. Almost one-third of patients with a traumatic CCS in Wales had died within five years of their injury. The type of management did not significantly affect mortality but their age at the time of injury did. Further work to assess the long-term functional outcomes of surviving patients is needed to generate more reliable prognostic information. Cite this article: Bone Joint J 2023;105-B(8):920–927

We assessed hyperextension of the knee and joint laxity in 169 consecutive patients who underwent an anterior cruciate ligament reconstruction between 2000 and 2002 and correlated this with a selected number of age- and gender-matched controls. In addition, the mechanism of injury in the majority of patients was documented. Joint laxity was present in 42.6% (72 of 169) of the patients and hyperextension of the knee in 78.7% (133 of 169). All patients with joint laxity had hyperextension of their knee. In the control group only 21.5% (14 of 65) had joint laxity and 37% (24 of 65) had hyperextension of the knee. Statistical analysis showed a significant correlation for these associations. We conclude that anterior cruciate ligament injury is more common in those with joint laxity and particularly so for those with hyperextension of the knee

Introduction. Instability continues to be the number one reason for revision in primary total hip arthroplasty (THA). Commonly, impingement precedes dislocation, inducing a levering out the prosthetic head from the liner. Impingement can be prosthetic, bony or soft tissue, depending on component positioning and anatomy. The aim of this virtual study was to investigate whether bony or prosthetic impingement occurred first in well positioned THAs, with the hip placed in deep flexion and hyperextension. Methods. Twenty-three patients requiring THA were planned for a TriFit/Trinity ceramic-on-poly cementless construct using the OPS. TM. dynamic planning software (Corin, UK). The cups were sized to best fit the anatomy, medialised to sit on the acetabular fossa and orientated at 45° inclination and 25° anteversion when standing. Femoral components and head lengths were then positioned to reproduce the native anteversion and match the contralateral leg length and offset. The planned constructs were flexed and internally rotated until anterior impingement occurred in deep flexion [Fig. 1]. The type (bony or prosthetic), and location, of impingement was then recorded. Similarly, the hips were extended and externally rotated until posterior impingement occurred, and the type and location of impingement recorded [Fig. 2]. Patients with minimal pre-operative osteophyte were selected as a best-case scenario for bony impingement. Results. 6/23 (26%) patients were planned with only a 32mm articulation (<50mm cup size), with the remaining 17 patients all planned with both 32mm and 36mm articulations (≥50mm cup size). Anterior impingement was 26% prosthetic and 74% bony with the 32mm articulations, and 100% bony with the 36mm articulations. Bony impingement in deep flexion was exclusively anterior neck on anterior inferior iliac spine. Posterior impingement was 57% prosthetic and 43% bony with the 32mm articulations, and 41% prosthetic and 59% bony with the 36mm articulations. Bony impingement in hyperextension was exclusively lesser trochanter (LT) on ischium. Of the patients planned with both 32mm and 36mm articulations, there was a 14% increase in prosthetic impingement when a 32mm head was planned (35% and 21% respectively). Discussion. Impingement in THA usually precedes dislocation and should be avoided with appropriate component positioning. We found that in hyperextension, prosthetic and bony impingement were equally common. In deep flexion, impingement was almost exclusively bony. Further studies should investigate the effects of stem version, cup orientation, liner design, cup depth, native offset and retained osteophytes on the type of impingement in THA. For any figures or tables, please contact the authors directly

Aims. Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in a motor impairment affecting the upper limbs more than the lower limbs, with occasional sensory impairment and urinary retention seen. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study is to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age. Patients and Methods. Patients ≥18 years with traumatic CCS between January 2012 and December 2017 in Wales were identified. Patient demographics and injury, management and outcome data was collected. Statistical analysis was performed to assess mortality and between group differences. Results. 65 patients were identified (66.2% male, mean age 63.9 years). At five-years follow-up, 32.3% (n=21) of CCS patients were dead. 6 (9.2%) patients had died within 31 days of their injury. 69.2% (n=45) of patients were managed conservatively and there was no significant difference (p=0.062) in age between conservatively and surgically managed patients. Kaplan-Meier analysis revealed no significant difference in mortality between patients managed conservatively compared to those managed surgically (log rank test, p=0.819). However, there was a significant difference (p=0.001) in mortality between the different age groups (<50 years vs 50–70 years vs >70 years). At five-years follow up, 55.6% of the patient group aged >70 years at time of injury were dead. Respiratory failure was the most common cause of death (n=9, 42.9%). Conclusion. Almost one third of patients with traumatic CCS in Wales were dead at five years following their injury. Management type did not significantly affect mortality, however age at time of injury did. Further work assessing the long-term functional outcomes of surviving patients is needed, to allow more reliable prognostic information and functional recovery predictions to be given

The success of total knee replacement (TKR) depends on optimal soft-tissue balancing, among many other factors. The objective of this study is to correlate post-operative anteroposterior (AP) translation of a posterior cruciate ligament-retaining TKR with clinical outcome at two years. In total 100 patients were divided into three groups based on their AP translation as measured by the KT-1000 arthrometer. Group 1 patients had AP translation < 5 mm, Group 2 had AP translation from 5 mm to 10 mm, and Group 3 had AP translation >  10 mm. Outcome assessment included range of movement of the knee, the presence of flexion contractures, hyperextension, knee mechanical axes and functional outcome using the Knee Society score, Oxford knee score and the Short-Form 36 questionnaire. At two years, patients in Group 2 reported significantly better Oxford knee scores than the other groups (p = 0.045). A positive correlation between range of movement and AP translation was noted, with patients in group 3 having the greatest range of movement (mean flexion: 117.9° (106° to 130°)) (p < 0.001). However, significantly more patients in Group 3 developed hyperextension > 10° (p = 0.01). In this study, the best outcome for cruciate-ligament retaining TKR was achieved in patients with an AP translation of 5 mm to 10 mm

Femoral head necrosis in the context of high impact gymnastics of young adolescents is rare but seems a more serious complication compared to a Perthes like necrosis. Between 2017 and 2019, three young females aged from12 to 14 years were referred due incapacitating hip pain and severe collapsing femoral head necrosis. The indication of hip preserving surgery was based on the extent of the necrosis, presence of a vital lateral pillar and joint subluxation. In one of our 3 cases total head involvement made THR necessary, which was performed elsewhere. In the remaining 2 cases, head reduction osteotomy plus periacetabular osteotomy led to a good and a fair result. Repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension/ external rotation could be the cause of severe femoral head necrosis in three adolescent female gymnasts we are reporting on. Supra-selective angiography or sonography may be helpful to improve indication. Targeted adaptation of training methods should be discussed. Due to the severe vascular insult, results have to be considered moderate

Retrospectively to analyse factors contributing to the development of hyperextension deformity after distal surgical lengthening of hamstrings in cerebral palsy. In the cohort of 51 diparetic patients (98 operated knees ) surgically treated for fixed flexion deformity at least five yers before this study was contemplated, the range of of hyperextension of the knee was measured. According to surgical technique two subgroups were differentiated:. A./ Simple cutting of gracilis and semitendinosus, followed by fractional lengthening of semimembranosus and biceps femoris. B./ Proximal stumps of gracilis and semitendinosus after its transverse division were anchored to fractionally lengthened semimembranosus. Assessment involved: Measurement of hyperextension of the knee in lying and standing position and by walking using video-documentation. Values of Bleck popliteal angle before and after operation were estimated. This cohort did not involve any case with residual fixed plantar flexion of the foot. Both surgical subgroups were compared for occurence of hyperextension deformity > 5° in lying, standing positions and by walking. Testing by Fisher exact test did not show any statistical difference in all three compared situations (p > 0,05). The occurence of hyperextension > 5°in lying position was found in 5 knees ( 5,1 %), in standing position in 8 knees ( 8,2 %) and by walking during stance phase in 12 knees (12,3 %). In no case hyperextension of the knee exceeded 15°. Statistical testing between the postoperative Bleck popliteal angle ( stratified into classes below 20° and over 20°) and the occurence of hyperextension deformity did not show in Fisher exact test any statistical significance. On the other side the testing between postoperative Bleck popliteal angle ( stratified as above) and the type of surgery showed statistical significancy in Fisher exact test. Simple cutting of gracilis and semitendinosus brought about oftener the lower values of Bleck popliteal angle below 20°. It seems that the role of type of treating superficial flexors in the ways used in this study was not so much decisive for development of hyperextension deformity