Distraction for proximal interphalangeal joint contractures: long-term results.

PURPOSE: To report the medium- to long-term outcomes of joint distraction using a unilateral external fixator in the treatment of chronic post-traumatic proximal interphalangaeal (PIP) joint contractures. METHOD: Between September 2001 and October 2011, 94 consecutive patients (98 PIP joints) with a mean age of 43 years (range, 17-69 y) were treated with external fixation for chronic flexion deformity of the PIP joint from trauma. The average time from injury to surgery was 48 months (range, 6-84 mo), and the duration of joint distraction was 10 days (range, 7-22 d). Patients were followed for a mean period of 54 months (range, 12-72 mo). RESULTS: The average gain in joint flexion was 25° and in joint extension was 40°. The mean improvement in the active range of movement was 67° (range. 30°-90°). There was no loss of motion on the latest follow-up. Patients younger than 40 years fared slightly better than those older than 40 years. Two patients developed swelling, pain, and erythema during treatment, which resolved upon temporarily stopping the distraction process. There were 12 cases of superficial pin-site infections, which were managed conservatively without serious complications or adverse outcome. CONCLUSIONS: External fixation is a simple and effective treatment modality for chronic traumatic PIP joint contractures with good predictable medium- to long-term results. Careful patient selection and monitoring are required.

Management of posttraumatic proximal interphalangeal joint contracture.

Chronic flexion contracture of the proximal interphalangeal (PIP) joint presents a common yet challenging problem to hand surgeons. Over the years, multiple treatment modalities have been described for this problem, producing limited results. Nonoperative treatment using serial casting and splints should be tried before attempting open surgical release, which should be done in selected patients. The use of external fixation for treating PIP contracture has been encouraging and can be a useful alterative. This review provides an update on the current management of PIP joint contractures and presents a flowchart of treatment to aid decision making.

Treatment of Rolando fracture by capsuloligamentotaxis using mini external fixator: a report of 16 cases.

Treatment of Rolando fractures remains a challenge for hand surgeons. We present a case series of 16 comminuted Rolando type fractures treated by controlled capsuloligamentous distraction (and over distraction by 2 mm) using the Pennig mini-external fixation system. Additional Kirschner wire(s) were used to maintain fracture reduction and stability. Average time of injury to surgery time was five days. Mean age of patients was 26 years. The mean follow-up was 20 months. Excellent fracture union was achieved in all cases. All except two patients were pain free at the final consultation. The mean grip and pinch strength of the affected thumb was 96% and 93%, respectively, of the unaffected thumb with a minimal loss of movements. This technique is simple and effective. It enables immediate mobilisation of the unaffected joints and prevents stiffness. We recommend this distraction technique for the treatment of significantly comminuted Rolando type fractures.

Post-traumatic cortical cysts in paediatric fractures: is it a concern for emergency doctors? A report of three cases.

Post-traumatic cortical bone cyst is a rare occurrence in children. It is typically located in the distal radius, as a result of greenstick fracture. We report three cases referred to our fracture clinic as a tumour in bones. In one of our cases, the cystic lesion was noted following a displaced fracture in the femur, which is not previously published in the literature. The cyst-like lesion appeared as an oval radiolucency proximal to the previous fracture site on radiograph films. These lesions can cause concern for the on-call teams as they can mimic an infection or a tumour of the bone. We highlight the pathogenesis of the lesion with a review of the literature.

Distraction correction of chronic flexion contractures of PIP joint: comparison between two distraction rates.

PURPOSE: The surgical correction of chronic flexion contractures of the proximal interphalangeal (PIP) joints is quite challenging because the extensive soft-tissue surgery needed is demanding, and the results often are discouraging. Gradual joint distraction recently was shown to be effective in the correction of PIP joint contractures. We performed this study to determine the optimum rate and amount of daily distraction and the optimum duration for which the external fixator should be left in situ after correction. This study compared 2 groups of patients with different distraction rates: one group with 0.5 mm/day and the other group with 1.0 mm/day. We also compared and evaluated the results of external fixation removal at 1 week versus 2 weeks after full correction. METHODS: The Mini-Orthofix external fixator was used to correct post-traumatic PIP joint contractures in 10 consecutive patients divided into 2 groups. Group 1 consisted of 5 patients who had 0.5 mm of joint distraction per day until full correction followed by an in situ external fixator for 2 weeks. Group 2 consisted of 5 patients who had 1 mm of joint distraction per day until full correction followed by an in situ external fixator for only 1 week. The 2 groups were compared and statistically analyzed. RESULTS: At the 1-year follow-up evaluation there were no statistically significant differences between the 2 groups. The mean range of motion gained was 64 degrees in group 1 and 66 degrees in group 2. There were no recurrences. CONCLUSIONS: We concluded that 1 mm of joint distraction per day followed by an in situ external fixator for 1 week may be safe and effective for the correction of chronic post-traumatic contractures of the PIP joint; however, similar studies on a larger group may be necessary before this technique could be recommended universally. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Epidemiology of bacterial hand infections.

OBJECTIVE: The aim of the study was to delineate and update the bacteriological spectrum, characterize patterns and sites of injury, evaluate laboratory tests and possible causes of complications in patients with bacterial hand infections. METHODS: All hand infections operated on in the department of orthopedics at Odense University Hospital during the period 1992-2001 were reviewed retrospectively. A standard protocol was used to collect data for each patient. We also examined all laboratory reports and recorded the identity of the etiologic organism, if known, for all cases of bacterial hand infections. RESULTS: Four hundred and eighteen patients (296 men and 122 women) with hand infections were operated on between 1992 and 2001 in our department. The median age of the patients was 40 years (range 1-93). The average interval from primary injury to operation was 10 days (range 1-50). The etiology was laceration/puncture in 35%. The site of infection was subcutaneous in 45% followed by tendon, joint and bone in 27, 18 and 5%, respectively. The bacteria isolated from the patients showed that 184 cultures (44%) were pure Staphylococcus aureus followed by 49 cultures (11.7%) of mixed organisms. Body temperature and C-reactive protein (CRP) were normal in three quarters of all patients with hand infections in our series. However the erythrocyte sedimentation rate (ESR) was elevated in 50% of the patients and was a significantly better test for infection in this study than CRP (p = 0.002). Neither the severity of infection nor the etiology of infection was related in any way to the initial temperature, CRP or ESR in this study. Complications were noted in 14.8% of all patients, and were especially related to diabetes, and mixed infection. CONCLUSION: Despite modern antibiotics, hand infections with a variety of organisms continue to be a source of morbidity and possible long-term disability. Most hand infections are the result of minor wounds that have been neglected. A complete history and physical examination is necessary to exclude other associated medical conditions (diabetes, arthritis, immunosuppression) that may compromise therapy. Furthermore, our study confirms that Staphylococcus aureus is responsible for most instances of hand infection, followed by mixed organisms. Gram-negative organisms are frequently cultured in patients with diabetes and intravenous drug abuse.

Forearm fractures in children. Single bone fixation with elastic stable intramedullary nailing in 20 cases.

We present our experience with elastic stable intramedullary nailing (ESIN) used in the single bone fixation of both bones forearm fractures in children. From May 2002 to July 2004, 20 children (14 boys and 6 girls), median age of 10 years (range 6-15 years) were treated with ESIN for 16 closed and 4 grade I open forearm fractures. All patients were reviewed clinically at a median follow-up of 20 months (range 6-30 months). All fractures were radiologically united at a median of 6.7 weeks (6-9 weeks). The median operating time was 35min (range 25-60min). The median hospital stay was 2 days (range 1-3 days). Removal of the nails was undertaken in all 20 children at a median of 19 weeks (range 16-24 weeks) post-operatively. At follow-up, a full range of elbow and wrist movements were found in all cases. There was no clinically significant rotational deformity in any case. ESIN seems to be a safe method in the treatment of single bone fixation of both bones forearm fractures in children between 6 and 15 years of age.

Remodeling of Salter-Harris type II epiphyseal plate injury of the distal radius.

The authors studied the relation between residual angulation at the time of healing and final orientation of the distal radius as well as the clinical outcome in patients after Salter-Harris type II epiphyseal plate injury of the distal radius. Eighty-five patients were reviewed with a median follow-up of 8.5 years. Anteroposterior and lateral radiographs were taken at follow-up. The mobility of both wrists and forearms was examined, together with grip strength. Pain with activities and sports was evaluated. At follow-up, 73 patients (86%) were anatomically normal on radiographs; the remaining 12 patients had an incomplete remodeling of the volar and/or radial inclination of the distal radius. Premature closure of the growth plate in the distal radius or ulna did not occur in any of these children. Complete remodeling was seen in children aged up to 10 years in all but one patient. Remodeling after Salter-Harris type II epiphyseal plate injury occurs in all age groups, but the potential is greater in children up to 10 years of age. The incomplete remodeling does not seem to have any substantial long-term negative effect on mobility of the wrist and grip strength.

Femoral shaft fractures in children: elastic stable intramedullary nailing in 31 cases.

We report our experience with elastic stable intramedullary titanium nailing (ESIN) of femoral shaft fractures in children. From 1998 to 2001, we treated 31 children (20 boys), median age 6 (4-11) years, with ESIN for 29 closed and 2 grade I open femoral shaft fractures. We reviewed 30 children clinically after median 1.5 (1-3) years. Their median hospital stay was 6 (2-20) days. All fractures were radiographically united at a median of 7 (5-9) weeks. The nails were removed in 29 children after a median of 22 (6-38) weeks postoperatively. At follow-up, we found a leg-length discrepancy up to 1 cm in 6 children and 10 degrees of internal rotational deformity in 1 child. No angular deformity had occurred. Elastic stable intramedullary nailing seems to be a safe method for the treatment of femoral shaft fractures in children between 4 and 11 years of age.

Distraction with external fixator for contractures of proximal interphalangeal joints: good outcome in 10 cases.

We present a new and simple technique for the treatment of proximal interphalangeal (PIP) joint contractures by mini Orthofix external fixator without open surgery. The technique was tested on 10 patients. We found that the fixator is easy to apply and effective in reducing contractures of the PIP joint by soft tissue distraction.

[Evaluation of multitraumatized patients admitted to a trauma center]. / Evaluering af multitraumatiserede patienter modtaget på traumecenter.

INTRODUCTION: This study describes the survival possibility in a population of Danish multitraumatized patients. The analysis is related to international standards and to development over time as well. MATERIAL AND METHODS: The study included 1664 patients admitted as trauma patients to the Odense University Hospital during the period January 1st 1996 to December 31st 2001. Demographic and injury related data were registered prospectively, as were basic data for scoring systems such as Abbreviated Injury Scale, Injury Severity Score, and Revised Trauma Score. These data were used in an analysis of the survival probability using the Trauma and Injury Score method. RESULTS: A number of 598 (36 per cent) patients had ISS > 15, whereas 724 (44 per cent) had NISS > 15. 71 per cent came from road traffic accidents. The overall mortality was 14 per cent. The survival probability using the Trauma and Injury Score method was significantly better than in American and British trauma databases despite comparable trauma severity. DISCUSSION: The treatment of multitraumatized patients at the Odense University Hospital is at least comparable to international standards and there seems to be an improvement of the survival probability during the study period 1996 to 2001. National cooperation aiming towards a national database would be desirable since it would then be possible to make regression analysis taking special Danish factors into consideration. This could lead to an improvement of the trauma care in trauma centres as well as in small hospitals.

Missed injuries in a level I trauma center.

BACKGROUND: Major trauma presents major diagnostic and therapeutic problems. Any delay in providing the treatment necessary may lead to increased morbidity and mortality, prolonged length of hospital stay, and increased cost. This study was undertaken to determine the extent, contributing factors, and implication of missed injuries and relate them to the three surveys in a Danish Level I trauma center. METHODS: The records of all major traumatized patients admitted to the Odense University Hospital from January 1996 through December 1999 have been studied to determine the extent and type of missed injuries. The initial examination is carried out by the trauma team in the A&E department according to standard protocols. Resuscitation is carried out according to Advanced Trauma Life Support principles and details are documented in the patient journal and in a special trauma journal. RESULTS: Sixty-four of 786 patients (incidence, 8.1%) had 86 missed injuries. The missed injuries averaged 1.3 injuries per patient. There were 45 male and 19 female patients, with a median age of 33 years (range, 12-81 years). The median ISS was 17 (range, 4-50); 14%, 38%, and 48% of the injuries were missed in primary, secondary, and tertiary surveys, respectively. CONCLUSION: Our study demonstrates that missed injuries can occur at any stage of the management of patients with major trauma. Repeated assessments, both clinical and radiologic, are mandatory to diminish the problem. In initial assessment, one still has to treat the greatest threat to life before complete diagnosis of all injuries, but alertness to evolving injuries must remain throughout the patient's stay in hospital.

Correction of congenital brachymetatarsia by gradual callus distraction.

Two children with congenital brachymetatarsia of the fourth metatarsal bone were treated by osteotomy of the metatarsal bone and bone lengthening by the Ilizarov technique. Both children were cosmetically improved.