Femoral neck osteosynthesis using interfragmentary compression or position screw in synthetic bones. What are the mechanical differences?

PURPOSE: We aim to compare interfragmentary compression with the position osteosynthesis in the fixation of different femoral neck fractures (FN) in synthetic bones subjected to vertical load. METHODS: Forty-two synthetic femurs were subjected to neck fractures and separated into 3 groups according to the Pauwels classification: Pauwels I had 6 units (PI); Pauwels II, 24 units, with and without comminution (PII); and Pauwels III, 12 units, with and without comminution (PIII). After, they were fixed with 2 different ways: three 7, 0 mm cannulated lag screws (CSs) versus three 6, 5 mm solid fully threaded screws (SSs). Screws positioning was oriented by the Pauwels classification: inverted triangle or crossed screws. All specimens were submitted to vertical loading until failure. RESULTS: The average force was 79.4 ± 22.6 Kgf. The greatest one was recorded in model 1 (135.6 Kgf), and the lowest in model 41 (39.6 Kgf). CSs and SSs had similar resistance until failure (p = 0.2). PI showed heightened resistance and PIII showed a worse response (p < 0,01). CSs had better performance in PIII (p = 0.048). Comminution and screws orientation caused no difference on peak force (p = 0.918 and p = 0.340, respectively). CONCLUSIONS: In synthetic bones, the resistance of a femoral neck fracture osteosynthesis using a 7, 0 mm cannulated lag screw or 6, 5 mm solid fully threaded screw are similar. There was no loss of efficiency with comminution in the femoral neck. Osteosynthesis resistance decreased with the verticalization of the fracture line and, in the more vertical ones, interfragmentary compression with CSs was more resistant than positional osteosynthesis with SSs.

"Preliminary evaluation of a prospective randomized case series comparing plate and screws versus Ilizarov circular external fixator for distal tibial fractures" / Avaliação preliminar de uma série de casos prospectiva e randomizada comparando placa e parafusos x fixador externo circular de Ilizarov para fraturas do pilão tibial

OBJECTIVE: to compare two surgical approaches for fractures of the tibial pilon: open reduction and internal fixation with plate and screws versus closed reduction and external fixation with the Ilizarov circular external fixator, constituting a study with a level of evidence level 4 and seeking to determine which patients benefit most from each surgical approach. METHODS: The research involved 19 patients with fractures of the tibial pilon, divided into two groups according to their respective medical records and evaluated considering the quality of joint reduction, acute complications in relation to these two methods and associated injuries and comorbidities due to a minimum outpatient follow-up of four months. RESULTS: there was no difference in terms of reduction quality, whereas in terms of acute complications and the need for surgical re-approaches, the group of patients undergoing open reduction and internal fixation with plate and screws showed worse results. CONCLUSION: the choice between the methods must be individualized, considering the specific injuries and comorbidities of each patient.

OBJETIVO: comparar duas abordagens cirúrgicas para fraturas do pilão tibial: redução aberta e fixação interna com placa e parafusos versus redução fechada e fixação externa com o fixador externo circular de Ilizarov, constituindo um estudo prospectivo randomizado e busca determinar quais pacientes se beneficiam mais com cada abordagem cirúrgica. MÉTODOS: A pesquisa envolveu 19 pacientes com fraturas do pilão tibial, divididos em dois grupos de acordo com seus respectivos números de prontuário e foram avaliados considerando a qualidade da redução articular, complicações agudas em relação a esses dois métodos e com lesões associadas e comorbidades por um seguimento ambulatorial mínimo de quatro meses. RESULTADOS: não houve diferença quanto a qualidade de redução, já em relação a complicações agudas e necessidade de reabordagens o grupo de pacientes submetido a redução aberta e fixação interna com placa e parafusos apresentou piores resultados. CONCLUSÃO: a escolha entre os métodos deve ser individualizada, considerando as lesões e comorbidades específicas de cada paciente.

Depression fractures of the posterolateral tibial plateau: Treatment by lateral femoral epicondyle osteotomy approach.

OBJECTIVE: The best surgical exposure and fixation method for fractures affecting the posterolateral corner of the tibial plateau remain debatable. This study describes a surgical approach to treat lateral depressions of the posterolateral tibial plateau with or without rim involvement by osteotomy of the lateral femoral epicondyle associated with osteosynthesis with a one-third tubular horizontal belt plate to stabilize the fracture fragment. METHOD: We evaluated 13 patients with fractures of the tibial plateau affecting the posterolateral region. Assessments included the degree of the depression (in millimeters), quality of the reduction, complications, and function. RESULTS: All fractures and osteotomies consolidated. The patients had a mean age of 48 years and were mostly men (n=8). Regarding the quality of the reduction, the mean reduction obtained was 15.8 mm, and 8 patients achieved anatomical reduction. The mean (± standard deviation) Knee Society Score was 92±13 (range 65-100), and the mean Function Score was 95±9.6 (range 70-100). The mean Lysholm Knee Score was 92±11.7 (range 66-100), and the mean International Knee Documentation Committee Score was 85±12.6 (range 63-100). All these scores reflect good results. None of the patients developed superficial or deep infection or presented healing disorders. Sensitive or motor complications of the fibular nerve were not observed. CONCLUSIONS: In this series of patients with depression fractures of the posterolateral tibial plateau, a surgical approach through osteotomy of the lateral femoral epicondyle allowed direct reduction and stable osteosynthesis of the fractures without functional impairment.

Importance of computed tomography in posterior malleolar fractures: Added information to preoperative X-ray studies.

BACKGROUND: Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures. AIM: To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture. METHODS: Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification. RESULTS: The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001). CONCLUSION: PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.

INTERFERENCE OF EXTERNAL DAMAGE CONTROL FIXATION IN DEFINITIVE OSTEOSYNTHESIS.

Introduction: Indications for provisional external fixation prior to the definitive treatment of fractures are associated with the control of local and systemic damage and the impossibility of definitive osteosynthesis in the emergency. Objective: To identify complications associated with external fixation prior to definitive internal osteosynthesis. Methods: This is a comparative, prospective study (Level II). Inclusion criteria: patients treated as emergencies (November 2019 and March 2020) who underwent provisional external correction followed by definitive osteosynthesis. We look for signs of inadequacies in external correction and correlation with infections (erythema, hyperemia, fistulae in the path of the pins or surgical scars), systemic symptoms of infection, and radiographic parameters for treatment up to eight weeks after surgery. Results: The average time for conversion to definitive osteosynthesis was 15.9 days and 47 lower limbs and three upper limbs were fixed. Of the participants who had deep infections, three (6%) showed signs during initial treatment (external fixator) and nine (18%), after definitive internal osteosynthesis. We found no correlation between provisional external correction and complications in the definitive treatment with osteosynthesis. Conclusion: The use of temporary external fixation before definitive internal osteosynthesis in fractures of the appendicular skeleton failed to increase complication rates even if the path of the implants in both procedures overlapped. Level of Evidence II, Comparative Prospective Study.

Introdução: As indicações para a fixação externa provisória que antecedem o tratamento definitivo das fraturas está associado ao controle do dano local e sistêmico e à impossibilidade de osteossíntese definitiva na urgência. Objetivo: Identificar complicações associadas à fixação externa precedente à osteossíntese interna definitiva. Métodos: Estudo prospectivo comparativo realizado com pacientes atendidos em situação de urgência entre novembro de 2019 e março de 2020, que sofreram a fixação externa provisória seguida de osteossíntese definitiva. Buscamos indícios de inadequações na fixação externa e correlação com: infecção (eritema, hiperemia, fístula do trajeto dos pinos ou da cicatriz cirúrgica), sintomas sistêmicos de infecção e parâmetros radiográficos da evolução do tratamento até oito semanas do pós-operatório. Resultados: O tempo médio para conversão em osteossíntese definitiva foi de 15,9 dias, e foram fixados 47 membros inferiores e 3 membros superiores. Dos participantes que apresentaram quadros de infecções profundas, três (6%) apresentaram os sinais durante o tratamento inicial (fixador externo) e nove (18%) após a osteossíntese interna definitiva. Não foi encontrada correlação entre a fixação externa provisória e complicações no tratamento definitivo com osteossíntese. Conclusão: O emprego da fixação externa temporária antes da osteossíntese interna definitiva em fraturas do esqueleto apendicular não provocou aumento nas taxas de complicações, mesmo quando houve sobreposição no trajeto dos implantes usados nos dois procedimentos. Nível de Evidência II, Estudo Prospectivo Comparativo.

Interference of external damage control fixation in definitive osteosynthesis / Interferência da fixação externa do controle de danos na osteossintese defintiva

ABSTRACT Introduction: Indications for provisional external fixation prior to the definitive treatment of fractures are associated with the control of local and systemic damage and the impossibility of definitive osteosynthesis in the emergency. Objective: To identify complications associated with external fixation prior to definitive internal osteosynthesis. Methods: This is a comparative, prospective study (Level II). Inclusion criteria: patients treated as emergencies (November 2019 and March 2020) who underwent provisional external correction followed by definitive osteosynthesis. We look for signs of inadequacies in external correction and correlation with infections (erythema, hyperemia, fistulae in the path of the pins or surgical scars), systemic symptoms of infection, and radiographic parameters for treatment up to eight weeks after surgery. Results: The average time for conversion to definitive osteosynthesis was 15.9 days and 47 lower limbs and three upper limbs were fixed. Of the participants who had deep infections, three (6%) showed signs during initial treatment (external fixator) and nine (18%), after definitive internal osteosynthesis. We found no correlation between provisional external correction and complications in the definitive treatment with osteosynthesis. Conclusion: The use of temporary external fixation before definitive internal osteosynthesis in fractures of the appendicular skeleton failed to increase complication rates even if the path of the implants in both procedures overlapped. Level of Evidence II, Comparative Prospective Study.

RESUMO Introdução: As indicações para a fixação externa provisória que antecedem o tratamento definitivo das fraturas está associado ao controle do dano local e sistêmico e à impossibilidade de osteossíntese definitiva na urgência. Objetivo: Identificar complicações associadas à fixação externa precedente à osteossíntese interna definitiva. Métodos: Estudo prospectivo comparativo realizado com pacientes atendidos em situação de urgência entre novembro de 2019 e março de 2020, que sofreram a fixação externa provisória seguida de osteossíntese definitiva. Buscamos indícios de inadequações na fixação externa e correlação com: infecção (eritema, hiperemia, fístula do trajeto dos pinos ou da cicatriz cirúrgica), sintomas sistêmicos de infecção e parâmetros radiográficos da evolução do tratamento até oito semanas do pós-operatório. Resultados: O tempo médio para conversão em osteossíntese definitiva foi de 15,9 dias, e foram fixados 47 membros inferiores e 3 membros superiores. Dos participantes que apresentaram quadros de infecções profundas, três (6%) apresentaram os sinais durante o tratamento inicial (fixador externo) e nove (18%) após a osteossíntese interna definitiva. Não foi encontrada correlação entre a fixação externa provisória e complicações no tratamento definitivo com osteossíntese. Conclusão: O emprego da fixação externa temporária antes da osteossíntese interna definitiva em fraturas do esqueleto apendicular não provocou aumento nas taxas de complicações, mesmo quando houve sobreposição no trajeto dos implantes usados nos dois procedimentos. Nível de Evidência II, Estudo Prospectivo Comparativo.

Treatment of femur pseudoarthrosis using wave plate: Evaluation of consolidation and its relationship with graft type.

INTRODUCTION: In the pathogenesis of femoral pseudoarthrosis, the arched shape of the bone is important when determining traction force on the anterolateral plane and posteromedial compression. In plate osteosynthesis, flexion forces affect the implant and can determine its breakdown and osteosynthesis failure. The wave plate seeks to solve the problem by transferring the support to the cortex under the plate or creating the resistance of a leaf spring. OBJECTIVES: To evaluate the bone healing pattern of femoral pseudoarthrosis treated with wave plate and its effectiveness in consolidation. MATERIALS AND METHODS: We retrospectively evaluated 18 patients with femoral pseudoarthrosis treated with wave plate. RESULTS: Three months after surgery, one patient presented healing of pseudoarthrosis, six months after surgery, 16 patients presented healing of pseudoarthrosis and at 12 months, all patients had complete bone healing. Regarding the type of pseudoarthrosis, nine patients had avascular and nine vascular pseudoarthrosis. Fifteen patients had medial cortical failure and three, lateral cortical failure. In all cases, consolidation started where there was bone failure, be it medial or lateral. DISCUSSION: The wave plate technique is well indicated for the existence of cortical bone failure, both in fractures and in pseudoarthrosis. Objective is to stabilize the fragments by transferring and allowing contact between them. The formation of the bone callus occurred in our sample from the region of the bone defect to the region of bone contact, using either a tricortical or cancellous bone graft. The elastic force of the wave and the eccentric distribution of loads in the femur favored the formation of a callus where it was distracted (bone failure) and the location with concentration of movement (proximity between the fragments) was the end of bone healing. CONCLUSION: The wave plate technique was effective in bone healing of femoral pseudoarthrosis, promoting consolidation from the cortical failure to the bone contact zone.

Epiphyseal fragment as a predictive factor of failure in fixation of proximal fractures of the humerus.

INTRODUCTION: Fractures of the proximal humerus are frequent and are widely studied with regards to their treatment indications. The aim of this article is to establish a correlation between the size of the epiphyseal fragment in fractures of the proximal humerus and the probability of loss of reduction after a surgical procedure. METHODS: A total of 47 surgically treated proximal humeral fractures were reviewed. Preoperative CT scans were used to evaluate the size of the epiphyseal fragment of the fracture. Postoperative X-rays were analyzed to assess complications, especially loss of reductions. Mean age was 61 years old (29-91 years). RESULTS: In total, 42 shoulders were evaluated. The average size of the epiphyseal fragment was 38.3 mm (32-50 mm) the largest longitudinal length; and 19.9 mm (12-30 mm) the largest cross-sectional length. The most frequent complication observed was loss of reduction. The statistical analysis showed significance that patients with smaller cross-sectional size of the epiphyseal fragment presented more complications (p = 0.034), and based on the graph and ROC curve, a value of 15.5 mm was considered as the cutoff value for failure. CONCLUSION: A cross-sectional length of the epiphyseal fragment of less than 15.5 mm indicates a higher probability of loss of reduction in fractures of the proximal end of the humerus after extra-medullary osteosynthesis.

Weight Discharge in Postoperative of Plateau Fracture Tibialis: Systematic Review of Literature.

Tibial plateau fractures are a risk to the functional integrity of the knee, affecting the axial alignment and capable of leading to pain and disability of the individual. Early weight bearing and joint mobilization can prevent these functional deficits. the goal of the present study was to conduct a systematic review of the literature about studies that quote the beginning, evolution, and progression criteria for weight-bearing in postoperative period of tibial plateau fractures. We selected articles published in the last 12 years, in Portuguese and English, that described the time of onset and progression of weight-bearing, considering the severity of the fracture. Thirty-six articles were selected. There is no consensus in the literature as to the beginning and evolution of weight-bearing in the postoperative period of tibial plateau fractures; however, a relationship between the severity of the fracture and the fixation method has been observed.

Weight Discharge in Postoperative of Plateau Fracture Tibialis: Systematic Review of Literature / Descarga de peso no pós-operatório de fratura de planalto tibial: Revisão sistemática da literatura

Abstract Tibial plateau fractures are a risk to the functional integrity of the knee, affecting the axial alignment and capable of leading to pain and disability of the individual. Early weight bearing and joint mobilization can prevent these functional deficits. the goal of the present study was to conduct a systematic review of the literature about studies that quote the beginning, evolution, and progression criteria for weight-bearing in postoperative period of tibial plateau fractures. We selected articles published in the last 12 years, in Portuguese and English, that described the time of onset and progression of weight-bearing, considering the severity of the fracture. Thirty-six articles were selected. There is no consensus in the literature as to the beginning and evolution of weight-bearing in the postoperative period of tibial plateau fractures; however, a relationship between the severity of the fracture and the fixation method has been observed.

Resumo As fraturas do planalto tibial constituem risco à integridade funcional do joelho, afetando o alinhamento axial e podendo levar à dor e à incapacidade do indivíduo. O suporte de carga e a mobilização articular precoce podem prevenir esses déficits e acelerar o processo de reabilitação. O objetivo do presente trabalho foi realizar uma revisão da literatura sobre estudos que citam o início, evolução e critérios de progressão do suporte de carga no pós-operatório das fraturas de planalto tibial. Foram selecionados artigos publicados nos últimos 12 anos, nos idiomas português e inglês, que descrevessem o tempo de início e progressão do suporte de carga, considerando a gravidade da fratura. Foram selecionados 36 artigos na literatura. Não há consenso na literatura quanto ao início e evolução do suporte de carga no pós-operatório das fraturas do planalto tibial. Contudo, observa-se relação entre a gravidade da fratura e o tempo de início da carga.

Fat embolism syndrome in femoral shaft fractures: does the initial treatment make a difference?

OBJECTIVE: To identify the risk factors correlated with the initial treatment performed. METHODS: This is a retrospective study involving a total of 272 patients diagnosed with femoral shaft fractures. Of the patients, 14% were kept at rest until the surgical treatment, 52% underwent external fixation, 10% received immediate definitive treatment, and 23% remained in skeletal traction (23%) until definitive treatment. RESULTS: There were six cases of fat embolism syndrome (FES), which showed that polytrauma is the main risk factor for its development and that initial therapy was not important. CONCLUSION: Polytrauma patients have a greater chance of developing FES and there was no influence from the initial treatment.

OBJETIVO: Identificar os fatores de risco e correlacioná-los com o tratamento inicial. MÉTODOS: Estudo retrospectivo que envolveu 272 pacientes com diagnóstico de fratura diafisária de fêmur; 14% permaneceram em repouso até o tratamento cirúrgico, 52% foram submetidos a fixação externa, 10% fizeram o tratamento definitivo imediato e 23% permaneceram com tração esquelética até o tratamento definitivo. RESULTADOS: Foram seis casos de síndrome da embolia gordurosa (SEG), nos quais se evidenciou que o politrauma é o principal fator de risco para seu desenvolvimento e que o tratamento inicial instituído não o influenciou. CONCLUSÃO: Pacientes politraumatizados apresentaram uma maior chance de desenvolver SEG e não houve influência do tratamento inicial instituído.

Fat embolism syndrome in femoral shaft fractures: does the initial treatment make a difference? / Síndrome da embolia gordurosa na fratura diafisária de fêmur: o tratamento provisório faz diferença?

ABSTRACT Objective: To identify the risk factors correlated with the initial treatment performed. Methods: This is a retrospective study involving a total of 272 patients diagnosed with femoral shaft fractures. Of the patients, 14% were kept at rest until the surgical treatment, 52% underwent external fixation, 10% received immediate definitive treatment, and 23% remained in skeletal traction (23%) until definitive treatment., Results: There were six cases of fat embolism syndrome (FES), which showed that , polytrauma is the main risk factor for its development and that initial therapy was not important. Conclusion: Polytrauma patients have a greater chance of developing FES and there was no influence from the initial treatment.

RESUMO Objetivo: Identificar os fatores de risco e correlacioná-los com o tratamento inicial. Métodos: Estudo retrospectivo que envolveu 272 pacientes com diagnóstico de fratura diafisária de fêmur; 14% permaneceram em repouso até o tratamento cirúrgico, 52% foram submetidos a fixação externa, 10% fizeram o tratamento definitivo imediato e 23% permaneceram com tração esquelética até o tratamento definitivo. Resultados: Foram seis casos de síndrome da embolia gordurosa (SEG), nos quais se evidenciou que o politrauma é o principal fator de risco para seu desenvolvimento e que o tratamento inicial instituído não o influenciou. Conclusão: Pacientes politraumatizados apresentaram uma maior chance de desenvolver SEG e não houve influência do tratamento inicial instituído.

Tibial shaft fracture and ankle injury - Case report.

The authors report on a case of tibial shaft fracture associated with ankle injury. The clinical, radiological and surgical characteristics are discussed. Assessment of associated injuries is often overlooked and these injuries are hard to diagnose. When torque occurs in the lower limb, the ankle becomes susceptible to simultaneous injury. It is essential to make careful assessment based on clinical, radiographic, intraoperative and postoperative characteristics in order to attain functional recovery.

Os autores relatam um caso de fratura diafisária de tíbia associado à lesão do tornozelo. As características clínicas, radiológicas e cirúrgicas são discutidas. A avaliação de lesões associadas são muitas vezes negligenciadas e de difícil diagnóstico. Quando um torque no membro inferior ocorre, o tornozelo fica suscetível a uma lesão simultânea. É essencial uma avaliação cuidadosa baseada no aspecto clínico, radiográfico, intra e pós-operatório para recuperação funcional.

Tibial shaft fracture and ankle injury - Case report / Fratura diafisária da tíbia e lesão do tornozelo - Relato de caso

ABSTRACT The authors report on a case of tibial shaft fracture associated with ankle injury. The clinical, radiological and surgical characteristics are discussed. Assessment of associated injuries is often overlooked and these injuries are hard to diagnose. When torque occurs in the lower limb, the ankle becomes susceptible to simultaneous injury. It is essential to make careful assessment based on clinical, radiographic, intraoperative and postoperative characteristics in order to attain functional recovery.

RESUMO Os autores relatam um caso de fratura diafisária de tíbia associado à lesão do tornozelo. As características clínicas, radiológicas e cirúrgicas são discutidas. A avaliação de lesões associadas são muitas vezes negligenciadas e de difícil diagnóstico. Quando um torque no membro inferior ocorre, o tornozelo fica suscetível a uma lesão simultânea. É essencial uma avaliação cuidadosa baseada no aspecto clínico, radiográfico, intra e pós-operatório para recuperação funcional.

Postoperative infection in patients undergoing inspection of orthopedic damage due to external fixation / Infecção pós-operatória nos pacientes submetidos ao controle de danos ortopédicos pela fixação externa

To conduct a retrospective analysis on cases undergoing inspection of orthopedic damage, at an orthopedic emergency service in a teaching hospital, with the aim of evaluating patients with postoperative infection after conversion to internal osteosynthesis. METHODS: This was a retrospective analysis covering the period from June 2012 to June 2013, on patients who underwent inspection of orthopedic damage due to external fixation and subsequently were converted to definitive osteosynthesis using a nail or plate. RESULTS: We found an infection rate of 13.3% in our sample and, furthermore, found that there had been technical errors in setting up the fixator in 60.4% of the cases. CONCLUSION: We found an infection rate that we considered high, along with inadequacies in constructing the external fixator. We emphasize that this procedure is not risk-free and that training for physicians who perform this procedure should be mandatory.

Fazer uma análise retrospectiva de casos submetidos ao controle de danos ortopédicos em um pronto socorro de ortopedia de hospital-escola com o objetivo de avaliar os pacientes com infecção pós-operatória após serem convertidos para osteossíntese interna. MÉTODOS: Análise retrospectiva de pacientes de junho de 2012 a junho de 2013 submetidos ao controle de danos ortopédicos com fixador externo que posteriormente foram convertidos para osteossíntese definitiva, com haste ou placa. RESULTADOS: Encontramos uma taxa de infecção de 13,3% em nossa casuística e verificamos erros técnicos na elaboração do fixador em 60,4% das oportunidades. CONCLUSÃO: Foi encontrada uma taxa de infecção que consideramos alta, assim como de inadequações na confecção do fixador externo. Salientamos que esse procedimento não é isento de riscos e treinamento para médicos que o fazem deve ser obrigatório.

Postoperative infection in patients undergoing inspection of orthopedic damage due to external fixation.

OBJECTIVE: To conduct a retrospective analysis on cases undergoing inspection of orthopedic damage, at an orthopedic emergency service in a teaching hospital, with the aim of evaluating patients with postoperative infection after conversion to internal osteosynthesis. METHODS: This was a retrospective analysis covering the period from June 2012 to June 2013, on patients who underwent inspection of orthopedic damage due to external fixation and subsequently were converted to definitive osteosynthesis using a nail or plate. RESULTS: We found an infection rate of 13.3% in our sample and, furthermore, found that there had been technical errors in setting up the fixator in 60.4% of the cases. CONCLUSION: We found an infection rate that we considered high, along with inadequacies in constructing the external fixator. We emphasize that this procedure is not risk-free and that training for physicians who perform this procedure should be mandatory.

OBJETIVO: Fazer uma análise retrospectiva de casos submetidos ao controle de danos ortopédicos em um pronto socorro de ortopedia de hospital-escola com o objetivo de avaliar os pacientes com infecção pós-operatória após serem convertidos para osteossíntese interna. MÉTODOS: Análise retrospectiva de pacientes de junho de 2012 a junho de 2013 submetidos ao controle de danos ortopédicos com fixador externo que posteriormente foram convertidos para osteossíntese definitiva, com haste ou placa. RESULTADOS: Encontramos uma taxa de infecção de 13,3% em nossa casuística e verificamos erros técnicos na elaboração do fixador em 60,4% das oportunidades. CONCLUSÃO: Foi encontrada uma taxa de infecção que consideramos alta, assim como de inadequações na confecção do fixador externo. Salientamos que esse procedimento não é isento de riscos e treinamento para médicos que o fazem deve ser obrigatório.

Tertiary survey in trauma patients: avoiding neglected injuries.

INTRODUCTION: Medical personnel in trauma centres in several countries have realised that undiagnosed injuries are common and are now focussing their attention on reducing the incidence of these injuries. Tertiary survey is a simple and easy approach to address the issue of undiagnosed injuries in trauma patients. Tertiary survey consists of reevaluating patients 24 hours after admission by means of an anamnesis protocol, physical examination, review of complementary tests and request for new tests when necessary. OBJECTIVE: To show the importance of tertiary survey in trauma patients for diagnosing injuries undetected at the time of initial survey. METHODS: A standardised protocol was used to perform a prospective observational study with patients admitted through the emergency department, Department of Orthopaedics and Trauma, Santa Casa de São Paulo. The patients were reevaluated 24 hours after admission or after recovering consciousness. New physical examinations were performed, tests performed on admission were reassessed and new tests were requested, when necessary. RESULTS: Between February 2012 and February 2013, 526 patients were evaluated, 81 (15.4%) were polytraumatised, and 445 (84.6%) had low-energy trauma. A total of 57 new injuries were diagnosed in 40 patients, 61.4% of which affected the lower limb. Diagnosis of 11 new injuries (19.3%) resulted in changes in procedure. CONCLUSION: The application of the protocol for tertiary survey proved to be easy, inexpensive and beneficial to patients (particularly polytraumatised patients) because it enabled identification of important injuries that were not detected on admission in a large group of patients.

Tertiary assessment of trauma patients in a hospital in the city of São Paulo: a question of necessity / Avaliacao terciaria em pacientes traumatizados em hospital na cidade de Sao Paulo: uma questao de necessidade

OBJECTIVE: To minimize the occurrence of missed injuries, the tertiary evaluation was introduced consisting of reassessment of the patient, 24 hours after admission, with: complete history, physical examination, review of exams and diagnostic testing if necessary. METHODS: Observational study evaluating trauma patients admitted to a teaching hospital in São Paulo, according to a protocol for tertiary evaluation. RESULTS: Between February and May 2012, for 12 weeks, 182 patients were submitted to tertiary evaluation, 100 (55%) polytraumatized and 82 (45%) were victims of low-energy trauma. Neglected lesions were observed in 21 (11.5%) patients, who had 28 missed injuries. Of these 28 lesions, seven (25%) required surgical treatment. CONCLUSION: Strategies including formal tertiary evaluation, the protocol applied for assessing trauma victims, seem to be beneficial in these patients, regardless of the mechanism of trauma. The method is easily applied, effective and has low cost in identifying missed injuries in the victims of trauma. .

OBJETIVO: Com o intuito de minimizar a ocorrência de lesões despercebidas, foi introduzida a avaliação terciária, que consiste na reavaliação do paciente, 24 horas após sua internação, com: anamnese completa, exame físico detalhado, revisão dos exames subsidiários e complementação diagnóstica se houver necessidade. MÉTODOS: Estudo observacional que avaliou pacientes vítimas de trauma internados em hospital escola na cidade de São Paulo, guiado por protocolo para avaliação terciária. RESULTADOS: Entre fevereiro e maio de 2012, durante 12 semanas, foram submetidos à avaliação terciária 182 pacientes vítimas de trauma, 100 (55%) politraumatizados e 82 (45%) vítimas de trauma de baixa energia. As lesões negligenciadas foram observadas em 21 (11,5%) pacientes, que apresentavam 28 lesões despercebidas. Dessas 28 lesões, sete (25%) necessitaram de tratamento cirúrgico. CONCLUSÃO: Estratégias que incluem avaliação terciária formal, aplicada nas vítimas de trauma, sugerem ser benéficas aos pacientes, independentemente do mecanismo de trauma. É método de execução fácil, custo financeiro barato e efetivo na identificação de lesões negligenciadas nas vítimas de trauma. .

Biomechanical study: resistance comparison of posterior antiglide plate and lateral plate on synthetic bone models simulating Danis-Weber B malleolar fractures / Comparação da resistência mecânica pela osteossíntese com placas fixadas nas posições lateral e posterior em fraturas Danis-Weber B: estudo experimental

OBJECTIVE: The purpose of this study was to compare different positions of plates in lateral malleolar Danis-Weber B fractures on synthetic bone: a lateral plate and a posterior antiglide plate. METHODS : Short oblique fractures of distal fibula at the level of the syndesmosys were simulated with a fibular osteotomy in sixteen synthetic fibula bones (Synbone®). Eight fractures were fixed with lateral plating associated with an independent lag screw, and the other eight were fixed with posterior antiglide plating with a lag screw through the plate. A strain gage was installed at the center of each plate at the osteotomy site. Supination and external rotation forces were applied to each of the two groups at the bend. RESULTS : The lateral position plate group suffered more deformity in response to supination forces compared to the group with the posterior antiglide plate, but this result was not statistically significant. In the tests with external rotation forces, the posterior antiglide plating group had significantly higher resistance (p < 0.05). CONCLUSION : When subjected to external rotation forces, osteosynthesis with posterior antiglide plate models simulating type B fractures of the lateral malleolus of the ankle is more resistant than that of the neutralization plate. .

OBJETIVO: Comparar a resistência mecânica da fixação do maléolo lateral do tornozelo com placa em posição lateral ou posterior com o maléolo em modelos de fíbula sintética, com simulação de fraturas tipo B de Danis-Weber. MÉTODO: A simulação da fratura em 16 fíbulas sintéticas (Synbone®) foi feita por corte oblíquo com serra oscilatória de 1 mm. Em oito modelos, a falha foi fixada por placa de neutralização (posição lateral); as demais por placa anticisalhante (posição posterior). Em seguida instalamos um extensômetro no centro de cada placa, visando a mensurar a deformação determinada pelas forças em supinação produzidas durante experimento na bancada nos dois grupos. Outro ensaio foi produzido com força de rotação externa sobre o implante. RESULTADOS : O grupo com osteossíntese de neutralização sofreu deformação maior aos esforços em supinação quando comparado com o grupo com placa anticisalhante, porém sem significância estatística. Nos ensaios com força em rotação externa houve significância estatística em favor da eficiência das placas posteriores (p < 0,05). CONCLUSÃO : A osteossíntese com placa anticisalhante em modelos que simulam fraturas tipo B do maléolo lateral do tornozelo é mais resistente do que a placa de neutralização quando submetidas às forças em rotação externa. .

Biomechanical Study: Resistance Comparison of Posterior Antiglide Plate and Lateral Plate on Synthetic Bone Models Simulating Danis-Weber B Malleolar Fractures.

OBJECTIVE: The purpose of this study was to compare different positions of plates in lateral malleolar Danis-Weber B fractures on synthetic bone: a lateral plate and a posterior antiglide plate. METHODS: Short oblique fractures of distal fibula at the level of the syndesmosys were simulated with a fibular osteotomy in sixteen synthetic fibula bones (Synbone®). Eight fractures were fixed with lateral plating associated with an independent lag screw, and the other eight were fixed with posterior antiglide plating with a lag screw through the plate. A strain gage was installed at the center of each plate at the osteotomy site. Supination and external rotation forces were applied to each of the two groups at the bend. RESULTS: The lateral position plate group suffered more deformity in response to supination forces compared to the group with the posterior antiglide plate, but this result was not statistically significant. In the tests with external rotation forces, the posterior antiglide plating group had significantly higher resistance (p < 0.05). CONCLUSION: When subjected to external rotation forces, osteosynthesis with posterior antiglide plate models simulating type B fractures of the lateral malleolus of the ankle is more resistant than that of the neutralization plate.