Treatment of grade IIIB and grade IIIC open tibial fractures.

The treatment of grade IIIB and grade IIIC open tibia fractures remains a challenge to the orthopedic surgeon. This article explores the history of clinical management, current methods of stabilization, and decision-making algorithms, special attention is given to the debate regarding limb salvage versus amputation.

Protected early motion versus cast immobilization in postoperative management of ankle fractures.

Sixty-one active-duty military personnel with operatively treated ankle fractures were randomized into two postoperative immobilization regimens: Group I--six weeks short-leg cast, nonweight-bearing; Group II--six weeks removable orthosis, nonweightbearing. Group I began physical therapy at six weeks postoperatively, and Group II began physical therapy within the first postoperative week. Objective measurements of swelling, strength, range of motion, and functional tests were examined. Subjective scores of pain, function, cosmesis, and motion were recorded. Patients in Group II (early mobilization) had significantly better subjective scores at three and six months postoperatively; however, time to return to duty was not significantly different. Objective tests of swelling, strength, range of motion, and functional tests were not significantly different at three months postoperatively for either group. Early mobilization in a removable orthosis, while not objectively altering the postoperative course, provides a safe, preferable method of treatment in the reliable and cooperative patient.

Multiple relaxing skin incisions in orthopaedic lower extremity trauma.

The purpose of this study was to evaluate the efficacy of using multiple relaxing skin incisions (MRSIs) to facilitate the closure of difficult lower extremity wounds. Such wounds are caused by direct trauma or by surgical intervention for management of bone and soft tissue injury that result in wound closure under tension. Common alternatives include closure by secondary intention, delayed primary closure, split thickness skin grafting, or flap coverage. The technique of MRSI involves numerous small (5-10 mm) incisions through the dermis arranged in 1-cm-wide rows parallel to the primary wound or incision. Multiple relaxing skin incisions were utilized in 22 cases of orthopaedic lower extremity trauma to facilitate primary or delayed primary closure. Wounds were evaluated for dehiscence, skin slough, superficial and deep infection, and neurovascular compromise in the early postoperative period. Cosmesis was evaluated long term. Patients were followed postoperatively for > or = 1 year. There were no cases of wound dehiscence, skin slough, infection, or neurovascular compromise. Multiple relaxing skin incisions were preferred by all patients when compared to split thickness skin grafting, open wound management, or flap coverage. Cosmetic results were excellent. The use of MRSIs is a safe, simple, and reliable technique where wound closure is complicated by swelling due to trauma or soft tissue defects. No specialized training or equipment is required, and postoperative wound care is greatly simplified.

The investigation of a tuberculosis outbreak in the closed environment of a U.S. Navy ship, 1987.

A sailor on a U.S. Navy ship had smear-positive, cavitary, pulmonary tuberculosis. Contact investigation of the entire ship's crew found 216 new reactors to tuberculin skin test (24.5%) among 881 previously tuberculin-negative sailors. The risk for new infection was highest among sailors in the patient's department (relative risk, 4.4; 95% confidence interval 3.7, 5.3); 95% (15/16) of sailors in his division were new reactors. While crewmembers in all departments were at risk for a new tuberculosis infection, working and berthing in compartments that were distant from those of the index case were protective. The ship's closed ventilation system contributed to the outbreak.