The soft tissues surrounding the spine play a primordial role in its stability, the most important of which are located posteriorly and are deemed the posterior ligamentous complex (PLC). Injuries to the PLC in the setting of thoracolumbar trauma are often dreaded and little attention has been given to them in the management protocols of thoracolumbar trauma. This review aims to summarize and contextualize current concepts in PLC injuries of the thoracolumbar spine with the aim to provide a clear guide for clinical management. Injuries to the PLC may be suspected on the clinical exam but are often missed, leading to serious complications, including instability and neurological compromise. The diagnosis is often made indirectly by spinal radiographs and CT-scanning or by direct visualization of soft tissues via magnetic resonance imaging. The latter remains the standard imaging modality and is mandatory for patients with a high suspicion of PLC injury. PLC injuries are associated with vertebral fractures and follow a progressive pattern of severity, depending on the mechanism of injury and extent of trauma. Surgical management is warranted, as PLC damage renders the spine unstable. Although fusion was once the standard of care and remains applicable for certain patients, recent endeavors of temporary spinal fixation without fusion are increasingly gaining traction in patients with PLC injuries. In conclusion, PLC injuries are challenging as they are often missed, poorly understood, and are not easily managed. Proper diagnosis and management are crucial to avoid long-standing complications such as spinal instability. Considering the paucity of available data on such an important topic in thoracolumbar trauma, this review article aims to contextualize current concepts in PLC injuries in order to demystify this sparsely covered subject.

Rationale: Hip-spine syndrome is a frequent finding in patients presenting with symptoms both at the level of the hip and spine. Patient concerns: Patient previously operated of lumbar laminectomy for supposed spinal stenosis presenting with persistent pain and disability. Diagnoses: Clinical examination and imaging showed severe bilateral hip osteoarthritis. Full body standing and sitting biplanar radiographs showed an associated severe sagittal malalignment. 3D motion analysis and health-related quality of life (HRQOL) questionnaires showed a severe functional impact. Interventions: He was operated of a staged bilateral total hip arthroplasty using the direct anterior approach. Outcomes: Spinopelvic and sagittal alignment parameters, as well as 3D motion analysis and HRQOL scores showed significant improvement after the first, then the second total hip arthroplasty. Lessons: Comprehensive functional diagnostic testing, including full body standing and seated radiographs, 3D gait analysis and HRQOL questionnaires may provide important information for future management.

The aim was to study the validity of free-standing position using modifiers for assessing cervical spine alignment. A total of 26 asymptomatic subjects (45 ± 11years) and 13 with spinal deformities (30 ± 21years) underwent lateral radiographs using EOS®, while adopting 3 different positions, in 2 sequences, without mirror and then with mirror (m) placed in front of them: first, the neutral standing position (upper extremities positioned on the sides of the body, P1 and P1m), then free-standing (P2 and P2m) and modified free-standing (P3 and P3m) positions (shoulders flexed at 90° and fingers placed on clavicles then cheeks, respectively). Participants were asked not to move their trunk and shoulders when moving from P1 to P2 and then P3. Eighteen cervical radiographic parameters were calculated from the 6 radiographs. The effects of shoulder flexion, mirror placement, and finger positioning on cervical alignment were studied using a repeated-measures ANCOVA. Mirror placement had no effect on cervical alignment. Concerning the effect of shoulder flexion, C2–C7 and T1 slopes were significantly decreased in P2 and P2m (C2–C7 = 10° and 8°; T1 slope = 26° and 24°, respectively) and P3 and P3m (C2–C7 = 9° and 9°; T1 slope = 25° and 26°, respectively) compared to P1 and P1m (C2–C7 = 14°and 14°; T1 slope = 29°and 30°, respectively), without exceeding the uncertainty level. Assessment of cervical alignment is valid on whole-spine radiographs when the shoulders are flexed (free-standing position). Clear instructions regarding the shoulder position at 90°, without moving the trunk, neck, and head before placing the fingers on the clavicles or cheeks, can ensure a cervical alignment comparable to that obtained with the neutral position, which is considered the most physiological one.

Elastic Stable Intramedullary Nailing (ESIN) is the treatment of choice for forearm fractures in children. However, fractures occurring at the distal metaphyseal-diaphyseal junction (DMDJ) of the radius are notoriously difficult to treat. This paper presents a modified ESIN method to treat these fractures. Surgical intervention was considered for fractures with angulation >10 ° in the coronal plane, 20 ° in the sagittal plane, >1 cm of bayoneting, and instability after reduction. A radial approach is used. Once the nail is at the biceps tuberosity, it is retracted by 4 cm and at bent 90 °, and reinserted so that the nail lies against the medial cortex, thereby stabilizing the fracture. Twenty-seven patients were treated, all showing <5° of coronal and sagittal tilt as well as <5 mm of coronal translation and <5° of difference in pronation-supination. This new ESIN method is an effective technique for the treatment of DMDJ fractures on the radius in children. LEVEL OF EVIDENCE: IV; Technical note and case series.