Intramedullary Steinmann pin nailing of the ulna: an option for the damage control orthopedics treatment of forearm fractures in open injuries in polytraumatized patients - A description of the technique and presentation of a case series.

INTRODUCTION: Forearm shaft fracture is common in young adult patients and associated with soft tissue and organ injuries. In open fractures in polytrauma patients, damage control orthopaedics (DCO) is well indicated. The aim of this study is to describe intramedullary Steinmann pin fixation of the ulna as a DCO procedure for the forearm and present a case series. DESCRIPTION OF THE TECHNIQUE: A 3.0 mm Steinmann pin is inserted retrograde in the ulna proximal fragment through the fracture site using the open wound as the approach. With direct visualization of the reduction, the pin is advanced into the distal fragment. The reduction of the longitudinal axis and shortening is thus achieved. PATIENTS AND METHODS: This method was used for all open fractures of forearm both-bone fractures in polytrauma patients undergoing DCO from 2014 to 2019. The alignment and length of the ulna were evaluated radiographically after pin fixation and before and after definitive fixation. Differences in the need for secondary procedures and infection rate between DCO and definitive fixation were also evaluated. RESULTS: There were 30 males (85.7%) with an average age of 32.9 ± 12.0 years and a mean ISS (Injury Severity Score) of 29.4 (range, 18.0-41.0). The most common associated injuries were thoracic trauma (62.8%) and head trauma (45.7%). In the radius and ulna, 51.4% and 60.0% of fractures, respectively, were multifragmentary (types B and C). Gustilo type IIIA represented 77.1% of the injuries. Pin fixation achieved good alignment and length in all cases. The mean time between DCO and definitive fixation was 12.0 days, and no secondary procedure was needed, nor any case developed either superficial or deep infection. The conversion from DCO to definitive fixation was considered easy in all cases. CONCLUSION: Intramedullary Steinmann pin fixation of the ulna is a viable option for DCO for forearm both-bone fractures in open fractures in polytrauma patients.

Factors associated with one year mortality in ill patients with proximal femoral fractures treated non operatively.

INTRODUCTION: Non-operative treatment is an exceptional indication for the treatment of proximal femur fracture. The aim of the study was to analyze the mortality rate in one year and associated factors in severely ill patients submitted to non-operative treatment. METHODS: It was included 28 patients treated from August 2014 to September 2019. Eighteen (64.3%) patients were female and 10 (35.7%) were male. The mean age was 78.7 ± 11.9 years old. The main outcome evaluated was the mortality rate in one year. It was also evaluated the correlation with gender, age, personal habits, number of comorbidities and Charlson Comorbidity Index (CCI). RESULTS: The functional result was assessed with WOMAC score via telephone call. The mortality rate in one year was 42.8% without statistical positive correlation with any of the studied parameters. Patients with three or more comorbidities didn't have a higher mortality rate comparing to survived patients (83.3% vs 81.3%). The CCI also didn't show any correlation with high mortality (6.9 vs 7.1). The functional result of the survived patients was poor (78.2 points WOMAC). CONCLUSION: The conclusion is that the mortality rate in one year of ill patients with hip fractures treated non-operatively is 42.8% without correlation with age, gender of number of comorbidities, and the functional result of the survived patients is poor.

Advances in treating exposed fractures.

The management of exposed fractures has been discussed since ancient times and remains of great interest to present-day orthopedics and traumatology. These injuries are still a challenge. Infection and nonunion are feared complications. Aspects of the diagnosis, classification and initial management are discussed here. Early administration of antibiotics, surgical cleaning and meticulous debridement are essential. The systemic conditions of patients with multiple trauma and the local conditions of the limb affected need to be taken into consideration. Early skeletal stabilization is necessary. Definitive fixation should be considered when possible and provisional fixation methods should be used when necessary. Early closure should be the aim, and flaps can be used for this purpose.

O manejo das fraturas expostas é discutido desde a antiguidade e permanece de grande interesse da ortopedia e da traumatologia modernas. São lesões ainda desafiadoras. Infecção e não união são complicações temidas. Aspectos no diagnóstico, classificação e manejo inicial são discutidos. São essenciais a administração precoce de antibióticos, a limpeza cirúrgica e o debridamento meticuloso. Devem ser levadas em consideração as condições sistêmicas do paciente politraumatizado e as condições locais do membro acometido. A estabilização esquelética precoce é necessária. A fixação definitiva deve ser considerada quando possível e métodos de fixação provisória devem ser usados quando necessário. O fechamento precoce deve ser almejado e pode-se fazer uso de retalhos para esse fim.

Outcomes evaluation of locking plate osteosynthesis in displaced fractures of the proximal humerus.

OBJECTIVE: To evaluate functional outcomes, radiographic findings and complications of proximal humeral fractures treated with locking plates and to determine prognostic factors for successful clinical outcomes. METHODS: Forty patients undergoing internal fixation of fractures of the proximal humerus with the Philos® plate were included in the study. The surgeries were performed between 2004 and 2011 and the patients underwent radiographic and clinical evaluation, by Constant-Murley and Dash score. Outcomes were analyzed by use of multivariate regression with several different variables. RESULTS: Patients were on average of 61.8 ± 16.28 years, and most were female (70%). The Constant-Murley score was 72.03 ± 14.01 and Dash score was 24.96 ± 19.99. The postoperative radiographs showed a head-shaft angle of 135.43° ± 11.82. Regression analysis showed that the patient's age and the Hertel classification influenced the Constant-Murley scale (p = 0.0049 and 0.012, respectively). Other prognostic criteria such as Neer and AO classification, head-shaft angle, the presence of metaphyseal comminution and extension of the humeral metaphyseal fragment showed no effect on prognosis. Complications occurred in four patients (10%). CONCLUSION: The fixation with the Philos® plate provided good clinical and radiographic results in fractures of the proximal humerus, with a low complication rate. Patient's age and Hertel classification were defined as prognostic factors that led to worse functional outcomes.

OBJETIVO: Avaliar os resultados clínicos e radiográficos e as complicações das fraturas do terço proximal do úmero tratadas com a placa Philos® e correlacionar esses resultados com critérios prognósticos. MÉTODOS: Foram estudados 40 pacientes submetidos a osteossíntese de fraturas do terço proximal do úmero com a placa Philos®. As cirurgias foram feitas entre 2004 e 2011 e os pacientes foram submetidos a avaliação funcional (escalas de Constant­Murley e Dash [Disability of Arm-Shoulder-Hand]) e radiográfica. Os resultados funcionais foram correlacionados com variáveis clínicas e radiográficas por meio de regressão múltipla. RESULTADOS: Os pacientes apresentavam em média 61,8 ± 16,28 anos e a maioria era do sexo feminino (70%). Observamos pontuação de 72,03 ± 14,01 pela escala de Constant­Murley e 24,96 ± 19,99 pela de Dash. A radiografia pós-operatória evidenciou um ângulo cabeça-diáfise de 135,43° ± 11,82. A análise por regressão demonstrou que a idade do paciente e a classificação de Hertel exercem influência direta na escala de Constant­Murley (p = 0,0049 e 0,012, respectivamente). Outros critérios prognósticos, como a classificação de Neer e AO, o ângulo cabeça-diáfise, a presença de cominuição metafisária e a extensão do fragmento metafisário não demonstraram influência no prognóstico em nossa amostra. Complicações ocorreram em quatro pacientes (10%). CONCLUSÃO: A osteossíntese com a placa Philos® proporcionou, em nossa amostra, bons resultados clínicos e radiográficos, com baixo índice de complicações. A idade do paciente e a classificação de Hertel foram demonstradas como fatores preditores do resultado funcional.