Presión intracompartimental y signos clínicos en pacientes con fracturas diafisarias en miembros inferiores ingresados en el IAHULA / Intracompartimental pressure and clinical Signs in patiens with diaphyseal fractures of the lower limbs admitted at IAHULA hospital

Las fracturas diafisarias del fémur y la tibia son las lesiones traumáticas más comunes a nivel mundial, afectan principalmente a la población joven y económicamente activa como consecuencia de traumatismos de alta energía, en su mayoría accidentes viales. Las complicaciones de estas lesiones han sido ampliamente descritas y las implicaciones médico-legales son importantes cuando estas no son detectadas a tiempo. Por lo que resulta relevante estudiar como se comportan las presiones intracompartimentales en las fracturas cerradas y su evolución en el tiempo, así como las manifestaciones clínicas durante las primeras 12 horas de evolución. Se realizó un estudio observacional transversal en 65 pacientes con fracturas cerradas diafisarias de fémur y tibia, evaluando las cifras de presión intracompartimental y las variables clínicas al momento de su ingreso y a las 12 horas de evolución intrahospitalaria. Encontramos que el compartimento más afectado es el anterior con un promedio de presión al ingreso de 22,26±6,90 mmHg. Asimismo, se demostró una relación directa entre el mecanismo y energía del trauma con respecto a las cifras de presión intracompartimental. Los resultados del estudio demostraron que el parámetro clínico más importante fue el dolor, el cual está relacionado con la energía del trauma(AU)

Diaphyseal fractures of the femur and tibia are the most common traumatic injuries worldwide, mainly affecting the young and economically active population as a consequence of high-energy trauma, mostly traffic related accidents. The complications of these injuries have been widely described and the legal implications are important when they are not detected early enough. Therefore, its relevant to study how intracompartmental pressures behave in closed fractures and their evolution, as well as the clinical manifestations during the first 12 hours. A cross-sectional observational study was made. 65 patients with closed diaphyseal fractures of the femur and tibia were included. The intracompartmental pressure numbers and the clinical variables at the time of admission and at 12 hours of in-hospital evolution were evaluated. As results, the most affected compartment is the anterior one with an average pressure at admission of 22.26 ± 6.90 mmHg. A direct relationship between the mechanism and energy of the trauma was also demonstrated with respect to the intracompartmental pressure levels reported. The most important clinical parameter was the pain, related to the energy of the trauma(AU)

Fratura condilar em criança de 4 meses: relato de caso / Condylar fracture in a 4-month-old-child: case report and literature review

Objetivo: apresentar um relato de caso clínico de uma criança de 4 meses de idade que sofreu uma fratura do côndilo após queda e foi submetida a tratamento conservador, discutindo aspectos que determinaram a opção por esta conduta. Relato de caso: paciente apresentava, no exame clínico, discreto edema na região do mento e não apresentava limitação da abertura bucal. Devido a estes achados clínicos e à idade do paciente, mesmo com imagem tomográfica evidenciando a fratura condilar, optou-se pela realização de tratamento conservador e acompanhamento clínico do paciente. Considerações finais: a decisão da conduta terapêutica deve ser baseada em exames físicos, clínicos e imaginológicos do paciente. Em pacientes muito jovens, como o relatado neste caso, é preciso ter cautela com a indicação dos procedimentos a serem realizados, pois é um paciente que está em intenso desenvolvimento e crescimento. O acompanhamento em longo prazo da manutenção de movimentação fisiológica da articulação temporomandibular do paciente também é fundamental para que se tenha sucesso no tratamento escolhido, evitando-se patologias como a anquilose ou outras alterações que dificultem uma abordagem mais conservadora ou minimamente invasiva. (AU)

Objective: the present study report a clinical case of a 4-month-old child who suffered a condyle fracture after falling and submitted to a conservative treatment, discussing issues that determined the option for this management. Case report: patient presented, on clinical examination, mild edema in the ment region and did not presented limitation of the oral opening. Due to these clinical findings and the patient's age, even with a tomographic image evidencing the condylar fracture, we chose to perform conservative treatment and clinical follow-up of the patient. Final considerations: the therapeutic management decision should be based in patient's physical, clinical and imaging examinations. In very young patients, as reported here, care should be taken to indicate the procedures to be performed, as it is a patient who is in intense development and growth. Long-term follow-up of the maintenance of the physiological movement of TMJ is also fundamental for the success of the treatment, avoiding pathologies such as ankylosis or other changes that hinder a more conservative or minimally invasive approach. (AU)

The Frequency of Occult Intertrochanteric Fractures among Individuals with Isolated Greater Trochanteric Fractures / 대한고관절학회지

PURPOSE: Isolated greater trochanteric (GT) fractures are often identified using plain radiography of patients with post-traumatic hip pain. In many cases, the fracture extends to form an occult intertrochanteric fracture. We conducted a study to determine the frequency of occult intertrochanteric fractures in patients diagnosed with isolated GT fractures using plain radiographs. MATERIALS AND METHODS: Among 3,017 individuals who visited our emergency department with a trauma-induced pertrochanteric femur fracture between July 2004 and March 2018, 100 patients diagnosed with isolated GT fractures using plain radiographs were retrospectively analyzed. Patients were divided into two groups, those with: i) isolated GT fractures (group A) and ii) occult intertrochanteric fractures (group B). In addition, plain radiographs, magnetic resonance imaging results, and treatment methods were further analyzed in each group. If surgery treatment was needed, it was performed by one surgeon, and in all cases, a 2-hole dynamic hip screw was used. RESULTS: Among the 100 cases of isolated GT fractures diagnosed using plain radiograph, additional examinations revealed that 10 (10.0%) were suffering from isolated GT fractures alone, while the remaining 90 (90.0%) were further diagnosed with occult intertrochanteric fracture. Gender, age, mechanism of injury, and bone mineral density did not correlate with fracture type. CONCLUSION: In our analysis, 90% of injuries initially diagnosed as isolated GT fractures were found to extend into occult intertrochanteric fractures upon further examination with additional imaging modalities. Therefore, additional evaluation should be performed to test for the potential presence of occult intertrochanteric fractures and to establish appropriate treatment plans.

A utilização da Ressonância magnética para auxílio do diagnóstico de fraturas por estresse: revisão sistemática / Magnetic resonance imaging in the diagnosis of stress fractures: a systematic review

Introdução: as fraturas por estresse são lesões causadas por fadiga ou insuficiência do osso acometido. Ocorrem após a formação e o acúmulo de micro fraturas nas trabéculas ósseas normais. Objetivo: avaliação das principais potencialidades do uso da Ressonância magnética para auxílio do diagnóstico de fraturas por estresse. Metodologia: 15 artigos foram selecionados nas línguas portuguesa e inglesa indexados nas bases de dados eletrônicos Web of Science, LILACS, SciELO, e Pubmed partindo dos descritores ressonância magnética, fraturas fechadas e diagnóstico, de acordo com os Descritores em Ciências da Saúde (DeCS). Resultado: foram analisados 68 artigos dos quais 53 artigos foram excluídos por não se enquadrarem nos critérios de seleção e 15 preencheram os critérios de inclusão. Conclusão: a ressonância magnética é o método mais indicado para se diagnosticar as fraturas por estresse, além de ser muito sensível e evidenciar as fraturas precocemente, além de não expor os pacientes à radiação ionizante.

Introduction: Stress fractures are injuries caused by fatigue or insufficiency of the affected bone. They occur after formation and the accumulation of micro fractures in normal bone trabeculae. Objective: to evaluate the main potentialities of magnetic resonance imaging to aid in the diagnosis of stress fractures. Methodology: 15 articles were selected in the Portuguese and English languages indexed in the electronic databases Web of Science, LILACS, SciELO, and Pubmed starting from the descriptors magnetic resonance, closed fractures and diagnosis, according to the Descriptors in Health Sciences (DeCS). Results: We analyzed 68 articles in which 53 articles were excluded because they did not fit the selection criteria and 15 met the inclusion criteria. Conclusion: magnetic resonance imaging the most appropriate method to diagnose stress fractures, as well as being very sensitive and showing fractures early, and not exposing patients to ionizing radiation.

The incidence and microbiological profile of surgical site infections following internal fixation of closed and open fractures / Infecção de sítio cirúrgico após fixação de fraturas fechadas e expostas - Incidência e perfil microbiológico

ABSTRACT OBJECTIVE: To evaluate the incidence and microbiological profile of surgical site infections (SSIs) associated with internal fixation of fractures and to compare differences in the SSIs observed among patients with closed and open fractures. METHODS: Retrospective study. Analyzed data included information from all patients who underwent surgery for fixation of closed or open fractures from January 2005 to December 2012 and remained outpatients for at least one year following surgery. Incidence of surgical site infection (SSI) was compared between patients with closed and open infection, as well as polymicrobial infection and infection related to Gram-negative bacilli (GNB). Cumulative antibiograms were performed to describe microbiological profiles. RESULTS: Overall incidence of SSI was 6%. This incidence was significantly higher among patients with open fractures (14.7%) than among patients with closed fractures (4.2%). The proportions of patients with polymicrobial infections and infections due to GNB were also significantly higher among patients with open fractures. Staphylococcus aureus and coagulase-negative Staphylococcus (CoNS) species were the primary infectious agents isolated from both groups. The overall incidence of MRSA (methicillin-resistant S. aureus) was 72%. A. baumannii was the predominant GNB isolate recovered from patients with open fractures and P. aeruginosa was the most frequent isolate recovered from patients with closed fractures, both exhibited low rates of susceptibility to carbapenems. CONCLUSIONS: Incidence of SSIs related to the internal fixation of fractures was significantly higher among patients with open fractures, indicating that an open fracture can be a risk factor for infection. Among the bacterial isolates, S. aureus (with a high prevalence of MRSA) and CoNS species were most prevalent. A. baumannii and P. aeruginosa isolates underscored the low rate of susceptibility to carbapenems that was observed in the present study.

RESUMO OBJETIVO: Avaliar a incidência e o perfil microbiológico das ISC relacionadas a procedimentos de fixação de fraturas num hospital acadêmico ortopédico terciário em São Paulo, Brasil, e comparar as diferenças observadas entre os pacientes com fraturas fechadas e expostas. MÉTODOS: Estudo retrospectivo. Foram incluídos na análise os dados relativos a todos os pacientes que passaram por procedimento cirúrgico para fixação de fraturas fechadas ou expostas de janeiro de 2005 a dezembro de 2012 e que mantiveram seguimento por pelo menos um ano. Foi verificada a presença de associação entre o tipo de fratura, a incidência de ISC e as incidências de infecções polimicrobianas e por bacilos Gram-negativos. O perfil microbiológico foi estabelecido por meio da elaboração de antibiogramas cumulativos. RESULTADOS: A incidência geral de infecção de 6%. Essa incidência foi maior no grupo de pacientes com fraturas expostas (14,7%) do que naqueles com fraturas fechadas (4,2%), com diferença estatisticamente significante. O número de pacientes com infecções polimicrobianas e com infecções relacionadas a BGN também foi significativamente maior no grupo de casos relacionados a fraturas expostas. Staphylococcus aureus e espécies de Staphylococcus coagulase-negativo (CoNS) foram os principais agentes isolados nos dois grupos. A incidência de MRSA (S. aureus resistente a meticilina) dentre todos os isolados de S. aureus foi de 72%. A. baumannii foi o principal BGN isolado entre os pacientes com fraturas expostas e P. aeruginosa entre os pacientes com fraturas fechadas. Em ambos os casos, observaram-se baixos índices de sensibilidade a carbapenêmicos. CONCLUSÕES: A incidência de ISC relacionada à fixação interna de fraturas foi significantemente maior nos pacientes com fraturas expostas, o que indica que esse tipo de fratura pode ser um fator de risco para a ocorrência desse tipo de infecção. Dentre os isolados bacterianos, predominaram no geral S. aureus (com elevada prevalência de MRSA) e S. coagulase-negativo. Dentre os BGN, houve predomínio de A. baumanni também entre os isolados de pacientes com fraturas expostas e P. aeruginosa entre os isolados daqueles com fraturas fechadas.

Implementation of a short course of prophylactic antibiotic treatment for prevention of postoperative infections in clean orthopaedic surgeries.

Background & objectives: Perioperative antimicrobial prophylaxis constitutes the bulk of antimicrobial consumption in any hospital. This study was conducted at a level 1 Trauma Centre of a tertiary care hospital of India to assess the efficacy of a short (24 h) course of perioperative antibiotic prophylactic regimen in preventing surgical site infections (SSI) in open reduction and internal fixation (ORIF) of closed fractures of limbs and to assess if the same can be implemented as a general policy. Methods: Patients of either sex, aged 18 yr or more, who were scheduled for ORIF and were willing and able to give informed consent, were included in the study. Patients were randomly allocated into two groups. Group 1 (n=100) received 3 doses of 1 g i.v. cefuroxime perioperatively spaced 12 h apart and group 2 (n=97) received the conventional existing regimen [5 days of i.v. antibiotics (cefuroxime 1 g twice daily along with amikacin 15 mg/kg in 2 divided doses), followed by oral cefuroxime, 500 mg twice daily till suture removal]. Results: Of the 197 patients, four patients developed a surgical site infection (three with methicillin resistant Staphylococcus aureus and one Acinetobacter baumanii). Of these, two patients were in group 1 and the remaining two in group 2. These patients were treated with i.v. antibiotics based on the culture and antimicrobial sensitivity reports. The cost of the short course treatment was ` 150 per patient as compared to ` 1,900 per patient for conventional regimen. Interpretation & conclusions: There was no significant difference in rates of SSI among the two groups in our study. Cost evaluation revealed that shorter course was less expensive than conventional long course regimen. Implementation of a short course perioperative regimen will go a long way in reducing antimicrobial resistance, cost and adverse reactions to antimicrobials.