Functional recovery following early mobilization after middle third clavicle osteosynthesis for acute fractures or nonunion: A case-control study.

BACKGROUND: Good outcomes have been reported after surgical treatment for acute or nonunion of displaced midshaft clavicle fractures. However, the postoperative rehabilitation and timeline for a complete functional recovery are poorly documented. The purpose of the current study was to evaluate the efficacy of an immediate motion protocol following plate fixation of a midshaft clavicle fracture and to compare functional recovery between acute and nonunion cases. METHODS: Between October 2011 and July 2015, all patients above the age of 18, having either an acute or a nonunion of the midshaft clavicle fracture, were considered as potentially eligible for inclusion in this prospective case-control study. Postoperatively, no immobilization was recommended and patients were to undergo rehabilitation protocol consisting of hourly stretching. RESULTS: Forty-two patients were included (31 with acute and 11 with delayed fixation) at a mean follow-up of 33months (range, 12 to 78months). Surgical complications consisted of one transient frozen shoulder, one delayed union, and two superficial infections. All patients returned to work, retrieved full shoulder range of motion (ROM), and returned to heavy sports and activities. Function returned faster in the acute group compared to the nonunion group based on the SANE score at 2weeks (73±21 vs. 45±26 respectively, P=0.01), SANE score at 6weeks (89±15 vs. 66±23 respectively, P=0.01), SANE score at 3months (96±10 vs. 85±14 respectively, P=0.03), and based on return of full ROM (17±25 vs. 44±31 days respectively, P=0.01). A trend was observed for nonunion cases needing more time to return to work and sports activities. CONCLUSION: Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment. An early mobilization rehab protocol can be safely recommended for both types of conditions and may result in substantial healthcare cost-savings, without increasing complication rate and decreasing patient satisfaction. LEVEL OF EVIDENCE: Level III; case-control study; treatment study.

Unstable pelvic ring injury with hemodynamic instability: what seems the best procedure choice and sequence in the initial management?

INTRODUCTION: Most fatalities related to pelvic ring injuries occur early and are caused by massive retroperitoneal bleeding. The objective of our study is to determine the optimal sequence of surgical procedures to restore hemodynamic stability in patients with unstable pelvic ring injuries. PATIENTS AND METHODS: This was a retrospective review of all patients with pelvic fractures and hemodynamic instability admitted to our level 1 trauma center between January 1998 and December 2008. We entered into our polytrauma database the following patient characteristics: age, sex, mechanism of injury, Injury Severity Score (ISS), classification of injury, timing of operative intervention, and type of operative procedures. Patients were divided into four groups (according to the sequence of surgical procedures performed within 24 hours following admission), as follows: group 1: patients treated with external fixation only; group 2: patients receiving external fixation followed by angiography; group 3: patients receiving external fixation followed by laparotomy ± angiography; and group 4: patients treated by immediate laparotomy or angiography before skeletal fixation. RESULTS: Eighty of 136 patients admitted with a pelvic fracture were classified, as unstable AO/OTA type B or C pelvic ring injury, and 70/80 were hemodynamically unstable. Eight patients died shortly after arrival and two remained stable without requiring any early procedure. Sixty patients went immediately to the operating room. Twenty-nine patients were placed in group 1 with 100% survival, 12 in group 2 with 91% survival, 11 in group 3 with 82% survival, and eight patients placed in group 4 with 0% survival (P<0.001). CONCLUSIONS: The management of hemorrhagic instability linked to pelvic ring disruption involves a sequence of therapeutic events, which is more important than the events themselves. Pelvic bone stabilization by pelvic clamp or external fixator followed by arteriography seems to be the more secure. Angiographic embolization is the method of choice whenever haemodynamic instability coexists with an unstable pelvic disruption. Laparotomy and packing are restricted to extreme severe cases in remote hospitals with skillful surgeons! Actually aortic balloon is a good solution to control uncontrollable bleeding. LEVEL OF EVIDENCE: Level IV. Retrospective study.

[Pit falls in the emergency walk-in clinic: the spine]. / Pièges en orthopédie ambulatoire: rachis (3).

Spine is always a great deal in tramatology. Complete clinical exam associated to plain Xray is the best challenge. CT-scan is preferred when there is osteoarthritis. IRM is used to check ligaments ("coup du lapin") or for medullar contusion.

Anatomy of the anterior cruciate ligament.

The anterior cruciate ligament (ACL) is a band of dense connective tissue which courses from the femur to the tibia. The ACL is a key structure in the knee joint, as it resists anterior tibial translation and rotational loads. When the knee is extended, the ACL has a mean length of 32 mm and a width of 7-12 mm. There are two components of the ACL, the anteromedial bundle (AMB) and the posterolateral bundle (PLB). They are not isometric with the main change being lengthening of the AMB and shortening of the PLB during flexion. The ACL has a microstructure of collagen bundles of multiple types (mostly type I) and a matrix made of a network of proteins, glycoproteins, elastic systems, and glycosaminoglycans with multiple functional interactions. The complex ultrastructural organization and abundant elastic system of the ACL allow it to withstand multiaxial stresses and varying tensile strains. The ACL is innervated by posterior articular branches of the tibial nerve and is vascularized by branches of the middle genicular artery.

[Mountain frostbite. A new approach to early prognosis. A study of 1,267 cases]. / Les gelures de montagne. Nouvelle approche du pronostic précoce. A propos de 1,267 cas.

Regarding an important series of mountain frostbite (1,267 cas), the authors try to explain the physiopathological mechanism. They expose the different methods that make possible nowadays an early prognosis. They set forth the treatment that seems still limited to save what can be spared; and this is valid for severe frostbite, the only ones to put problems. The quick warming up is the keystone of the treatment.

[Mountain frostbite (apropos of 1260 recorded cases)]. / Les gelures de montagne (à propos d'une statistique de 1260 cas).

Based on an important statistic of mountain frostbite (1260 cases), the authors try to explain the underlying physiopathological mechanism which remains largely unknown. An early prognosis may nowadays be improved by several diagnostic tools whose efficiency is reviewed. Difficult problems arise with severe frostbite only. In those cases, the treatment as such seems still limited to saving what has been spared. In any case, a quick warming up is the keystone of the treatment.

[Hang-gliding accidents in high mountains. Apropos of 200 cases]. / Les accidents de parapente en haute montagne. A propos de 200 cas.

A review of 200 cases of "paragliding" accidents in high mountain areas has been completed. The first flights have been murderous, a thesis written in 1987 in Grenoble showing seven dead out of 97 casualties. Since then the statistics seen to be improving as a consequence of the setting of regulations and the establishment of "paragliding" schools. The more frequent accidents happen on landing: in 70% of the cases fractures of the "tibiotarsienne", the wrist and the spinal column prevail. They happen to young adults between 20 and 40 years old, with a variable experience. Preventive measures consist in a greater prudence, a good physical condition and a precise aerological knowledge. The adepts of this sport have understood that wearing a helmet and appropriate shoes could reduce the gravity of the accidents. "Paragliding" if not a dangerous sport is certainly a risky one.