Engineering case report. Toluene and methyl ethyl ketone exposure from a commercially available contact adhesive.

A maintenance worker became ill after working indoors over the course of 3 days with a commercially available contact adhesive containing toluene and methyl ethyl ketone. Respiratory protection or local exhaust ventilation was not used. The worker subsequently suffered from numerous medical symptoms including tremors and elevated blood pressure. Magnetic resonance imaging documented the occurrence of encephalopathy. The worker has alleged that the cause of these effects was exposure to the vapors from the contact adhesive. The objective of this study was to characterize/estimate the level of the worker's exposure by obtaining air samples in an exposure chamber while performing similar activities under similar conditions. We found that the worker may have been exposed to approximately 159 ppm toluene and 58 ppm methyl ethyl ketone 8-hr time-weighted averages for 8 hr of adhesive application. The maximum 15-min average exposures were 233 ppm toluene and 85 ppm methyl ethyl ketone.

Influence of crystallographic texture on Young's modulus of various Alloy 82H welds.

Electron backscatter diffraction (EBSD) was employed to analyze the microstructure and texture of four different Alloy 82H gas tungsten arc welds that previously underwent static and dynamic modulus testing. The Young's moduli were shown to differ among the various welds, but also within each weld, dependent upon the direction measured. These differences were attributed to anisotropy of the crystallographic textures, which were described using inverse pole figures with respect to each of the weld's three orthogonal axes. The Young's modulus demonstrated a strong correlation with the texture, consistent with single crystal experiments. Sample directions containing a large population of {100} orientations had the lowest Young's modulus, while those with {111} grains possessed the highest. Microstructures with {110} textures were closer to the average modulus value of 207 GPa (30.0 Msi). X-ray diffraction texture measurements on four samples were used to verify the EBSD results.

Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes.

OBJECTIVES: To report clinical and functional outcomes following fixation of tibial posterior cruciate ligament (PCL) avulsion fractures through a modified open posterior approach when combined with a rehabilitation program emphasizing early range of motion. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS: From March 4, 2000 to May 8, 2003, there were 16 cases of PCL tibial avulsion injuries presented to our institution, with 10 patients available for follow up at 12 to 48 months (mean 28 months). INTERVENTION: Fixation of tibial PCL avulsion fractures was with a lag screw and washer placed through a modified open posterior approach. Range of motion was begun on postoperative day 1. MAIN OUTCOME MEASUREMENTS: Clinical stability, range of motion, gastrocnemius muscle strength, radiographic appearance, and each patient's overall health-related quality of life (using the musculoskeletal functional assessment tool) were evaluated at final follow up. RESULTS: The average musculoskeletal functional assessment score was 14. (Musculoskeletal functional assessment scores range from 0-100, with higher scores indicating poorer function.) All patients achieved union of their fracture and had clinically stable knees at the latest follow-up. Flexion difference greater than 10 degrees (P = 0.16), extension difference greater than 2 degrees (P = 0.38), and heel raise difference more than 8 repetitions (P = 0.23) were not demonstrated in comparison to the normal side. CONCLUSIONS: Treatment of tibial PCL avulsion fractures, which includes fixation through a modified open posterior approach and early postoperative range of motion, results in healing of the fracture, good functional outcomes, stability to posterior draw testing, and does not lead to gastrocnemius weakness or significant range of motion deficits at 12 to 48 months postoperatively.

Emissions of polychlorinated biphenyls (PCBs) from sludge drying beds to the atmosphere in Chicago.

Ambient air PCB concentrations in the Lake Calumet region in Southeast Chicago have been found to be significantly higher than in nearby non-urban areas. This area is highly industrialized and also contains municipal sludge drying facilities and landfills. In an effort to quantify the importance of the sludge drying facilities to the elevated concentrations, upwind/downwind air samples from the Calumet East sludge drying bed were obtained between April and October 2002. For these samples, the downwind minus upwind (downwind-upwind) concentration varied from 0.33 to 1.27ngm(-3) for non-northeast (NE) direction winds suggesting sludge drying is a source of PCBs to the atmosphere. However, the upwind concentrations were higher than the downwind for winds from the NE of the sampling site suggesting more significant source(s), possibly Lake Calumet or the so called "Cluster site" NE of the sludge drying beds. Flux chamber experiments carried out during the sampling period measured average PCB fluxes of 210ngm(-2)h(-1) (range 43-910ngm(-2)h(-1)) which resulted in an overall flux of 0.005kgday (d)(-1) ( approximately 2kgyr(-1)). A developed regression equation between moisture content and sludge concentration estimated higher PCB losses of 0.26kgd(-1) ( approximately 95kgyr(-1)). Although these two approaches yielded different values, they both indicate that the emission from the Calumet East sludge drying beds were of minimal importance when compared to the total estimated amount of 2-70kgd(-1) (700-2100kgyr(-1)) of PCBs entering the Chicago atmosphere.

Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates.

BACKGROUND: Plate fixation of comminuted bicondylar tibial plateau fractures remains controversial. This retrospective study was performed to evaluate the perioperative results and functional outcomes of medial and lateral plate stabilization, through anterolateral and posteromedial surgical approaches, of comminuted bicondylar tibial plateau fractures. METHODS: Over a seventy-seven-month period, eighty-three AO/OTA type-41-C3 bicondylar tibial plateau fractures were treated with medial and lateral plate fixation through two exposures. Injury radiographs were rank-ordered according to fracture severity. Immediate biplanar postoperative radiographs were evaluated to assess the quality of the reduction. The Musculoskeletal Function Assessment (MFA) questionnaire was used to evaluate functional outcome. RESULTS: Twenty-three male and eighteen female patients (average age, forty-six years) who completed the MFA questionnaire were included in the study group. The mean duration of follow-up was fifty-nine months. Two patients had a deep wound infection. Complete radiographic information was available for thirty-one patients. Seventeen (55%) of those patients had a satisfactory articular reduction (< or =2-mm step or gap), twenty-eight patients (90%) had satisfactory coronal plane alignment (medial proximal tibial angle of 87 degrees +/- 5 degrees ), twenty-one patients (68%) demonstrated satisfactory sagittal plane alignment (posterior proximal tibial angle of 9 degrees +/- 5 degrees ), and all thirty-one patients demonstrated satisfactory tibial plateau width (0 to 5 mm). Patient age and polytrauma were associated with a higher (worse) MFA score (p = 0.034 and p = 0.039, respectively). When these variables were accounted for, regression analysis demonstrated that a satisfactory articular reduction was significantly associated with a better MFA score (p = 0.029). Rank-order fracture severity was also predictive of MFA outcome (p < 0.001). No association was identified between rank-order severity and a satisfactory articular reduction (p = 0.21). The patients in this series demonstrated significant residual dysfunction (p < 0.0001), compared with normative data, with the leisure, employment, and movement MFA domains displaying the worst scores. CONCLUSIONS: Medial and lateral plate stabilization of comminuted bicondylar tibial plateau fractures through medial and lateral surgical approaches is a useful treatment method; however, residual dysfunction is common. Accurate articular reduction was possible in about half of our patients and was associated with better outcomes within the confines of the injury severity.

Osteochondral fracture of the distal lateral femoral condyle: a report of two cases.

Osteochondral fractures of the lateral femoral condyle are uncommon injuries. These fractures often are misdiagnosed, and the majority of the cases reported have been managed with surgical excision. We present 2 cases of osteochondral fractures of the lateral femoral condyle. Both patients were treated with open reduction internal fixation of their fractures. A lateral approach to the posterolateral aspect of the distal femur is described.

Polybrominated diphenyl ethers in the sediments of the Great Lakes. 4. Influencing factors, trends, and implications.

A total of 199 sediment samples were collected from 16 locations in the five Laurentian Great Lakes, and each was analyzed for 10 congeners of polybrominated diphenyl ethers (PBDEs) as well as selected polychlorinated biphenyls (PCBs). This paper presents a comprehensive analysis on previously published results for individual lakes. The total accumulation of nine tri- to hepta-PBDE congeners (sigma9BDEs) in the sediments of all the Great Lakes was estimated to be approximately 5.2+/-1.1 tonnes, and that of decabromodiphenyl ether (BDE209) was 92+/-13 tonnes, around year 2002. The inventories of sigma9BDEs and major individual PBDE congeners show strong dependence on the latitude of sampling sites, and such dependence is believed to reflect both the influence of urbanization, which shows south-to-north gradient in the region, and the general direction of long-range transport of airborne pollutants in the northern hemisphere. From the 1970s to 2002, the increases in PBDE input flux to the sediments are exponential at all locations, with doubling times (t2) ranging from 9 to 43 years for sigma9BDEs, and from 7 to >70 year for BDE209. The longer t2 values found in sediments compared with those in human and fish in the region suggest the slower response of sediment to emissions. The correlations between the concentrations of sigma9BDEs or BDE209 in surface sediments and latitude are strengthened by normalization of the concentrations with sediment contents of the organic matter or organic carbon, but not soot carbon. Multivariate linear regression equations were developed using data obtained with sediment segments deposited after 1950. All the regressions are statistically significant; and the three independent variables-year of deposition, latitude, and organic matter content of the sediments-account for 73% and 62% of the variations in the concentrations or the fluxes of S9BDEs and BDE209, respectively, in the Great Lakes sediments.

Polybrominated diphenyl ethers in the sediments of the Great Lakes. 3. Lakes Ontario and Erie.

Sediment cores were taken in 2002 in Lakes Ontario and Erie at four locations. A total of 48 sediment samples were characterized, dated using 210Pb, and analyzed for 10 congeners of polybrominated diphenyl ethers (PBDEs) including BDE209 as well as 39 congeners of polychlorinated biphenyls (PCBs). The surficial concentrations of nine tri- through hepta-BDE congeners (sigma9PBDE) are 4.85 and 6.33 ng g(-1), at sampling sites ON40 and ON30 in Lake Ontario, and 1.83 and 1.95 ng g(-1) at ER37 and ER09 in Lake Erie, respectively, based on dry sediment weight. The surficial BDE209 concentrations are 242 and 211 ng g(-1) at ON40 and ON30 and 50 and 55 ng g(-1) at ER37 and ER09. The sigma(9-) PBDEs fluxes to the sediment around 2002 are 147 and 195 pg cm(-2) year(-1) at ON40 and ON30 and 136 and 314 pg cm(-2) year(-1) at ER37 and ER09, respectively. The fluxes of BDE209 are 6.5 and 7.3 ng cm(-2) year(-1) at ON30 and ON40 and 3.7 and 8.9 ng cm(-2) year(-1) at ER37 and ER09, respectively. Dramatic increases in PBDE concentrations and fluxes upward toward the sediment surface and the present time are evident at both locations in Lake Ontario, while PCBs concentrations peak in the middle of sediment cores around the dated time of 1970s and 1960s. For both locations of Lake Erie, the increasing trends of both PBDEs and PCBs from the bottom to the surficial segments were distorted by sediment mixing. BDE209 is the most abundant congener among PBDEs in the sediments, constituting about 96 and 91% of the total PBDEs on mass basis in Lakes Ontario and Erie, respectively.

Provisional plating of Type III open tibia fractures prior to intramedullary nailing.

Intramedullary nailing of tibial shaft fractures is the preferred treatment of most displaced, unstable tibial shaft fractures. In open tibia fractures, direct exposure of the fracture segments for irrigation and debridement is required prior to fracture stabilization. We propose a method of provisional stabilization using commonly available implants placed through the associated traumatic open wound prior to intramedullary nailing. This technique, particularly helpful to surgeons operating with limited assistance, employs a temporarily applied 3.5-mm dynamic compression plate or limited contact dynamic compression plate implant secured with unicortical screws, allowing reaming and intramedullary nailing of a reduced, stabilized tibia fracture.

Polybrominated diphenyl ethers in the sediments of the Great Lakes. 2. Lakes Michigan and Huron.

Sediment cores were taken in 2002 in Lakes Michigan and Huron at six locations. A total of 75 samples were characterized, dated using 210Pb, and analyzed for 10 congeners of polybromodiphenyl ether (PBDE) including BDE209, as well as 39 congeners of polychlorinated biphenyls (PCBs). The concentrations of nine tri- through hepta-BDE congeners (Sigma9PBDE) in the surficial sediments range from 1.7 to 4 ng g(-1) for Lake Michigan and from 1.0 to 1.9 ng g(-1) for Lake Huron, on the basis of the dry sediment weight. The Sigma9PBDEs fluxes to the sediment around the year 2002 are from 36 to 109 pg cm(-2) yr(-1) in Lake Michigan and from 30 to 73 pg cm(-2) yr(-1) in Lake Huron, with spatial variations in both lakes. The flux of BDE209 ranges from 0.64 to 2.04 ng cm(-2) yr(-1) and from 0.67 to 1.41 ng cm(-2) yr(-1) in Lake Michigan and Lake Huron, respectively. Dramatic increases in PBDE concentrations and fluxes upward toward the sediment surface and the present time are evident at all locations. The inventory of PBDEs in both lakes appears to be dependent upon latitude and the proximity to populated areas, implying that north-bound air plumes from urban areas are the major sources of PBDEs found in the lake sediments at locations away from the shores. Heavier congeners are more abundant in the sediments than in air and fish samples in the region. BDE209 is about 96% and 91% of the total PBDEs on a mass basis in Lake Michigan and Lake Huron, respectively; both are higher than the 89% found in Lake Superior, although a t test shows that the value for Lake Huron is not statistically different from that for Lake Superior at the 95% confidence level.

Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique.

OBJECTIVES: Single incision open reduction and double plate fixation of complex tibial plateau fractures has been associated with high wound complication rates. Minimally invasive methods have been recommended to decrease the wound complication rates as compared with open techniques. Additionally, laterally applied fixed-angle devices appear to minimize late varus deformity without the need for additional medial stabilization. Accurate reduction of comminuted lateral and/or medial articular surfaces, however, often requires visualization through an open reduction. This study reports the complications, infection rate, and radiographic assessment of reduction associated with double plating complex AO/OTA 41-C3 tibial plateau fractures utilizing 2 incisions. DESIGN: Retrospective clinical review. SETTING: Urban level 1 university trauma center. PATIENTS: Over a 77-month period, 83 patients were treated for a complex bicondylar tibial plateau fracture at our institution utilizing a 2-incision technique. INTERVENTION: Dual plating using anterolateral and posteromedial incisions. MAIN OUTCOME MEASURE: Type and incidence of septic and non-septic complications and radiographic assessment of articular reduction and axial alignment. RESULTS: Eleven fractures were open (13.3%) and classified according to Gustilo as type II (1 patient), type III-A (7 patients), type III-B (2 patients), and type III-C (1 patient). Compartment syndrome was diagnosed and treated with fasciotomies in 12 patients (14.5%). The average time interval from injury to definitive surgical treatment was 9 days. Seven patients developed deep wound infections (8.4%). Three of these had an associated septic arthritis (3.6%). Clinical resolution of infection occurred after an average of 3.3 additional procedures. The presence of a dysvascular limb requiring vascular reconstruction was statistically associated with a deep wound infection (P = 0.006). Secondary procedures for complications included 13 patients who required removal of implants secondary to local discomfort, 5 patients who required a knee manipulation, 2 patients that were managed with excision of heterotopic ossification to improve knee motion, 1 patient that required an equinus contracture release, and 1 patient treated for a metadiaphyseal nonunion. Sixteen patients (19.3%) incurred deep venous thromboses. No patient was diagnosed with pulmonary embolism. Sixty-two percent of patients demonstrated satisfactory articular reductions, 91% demonstrated satisfactory coronal alignment, 72% demonstrated satisfactory sagittal alignment, and 98% demonstrated satisfactory condylar width. CONCLUSIONS: Comminuted bicondylar tibial plateau fractures can be successfully treated with open reduction and medial and lateral plate fixation using 2 incisions. Dysvascular limbs requiring vascular repair are at increased risk for deep sepsis. The use of 2 incisions, temporary spanning external fixation, and proper soft-tissue handling may contribute to a lower wound complication rate than previously reported.

Obtaining quantitative vapor emissions estimates of polychlorinated biphenyls and other semivolatile organic compounds from contaminated sites.

Soils contaminated with polychlorinated biphenyls (PCBs) and other semivolatile organic compounds (SVOCs) represent a potentially major, ongoing source of these compounds to the environment, especially during warmer temperatures. A great deal of work has been devoted to understanding the mechanisms that govern the vaporization of SVOCs from soil, but to date, few quantitative estimates have been published regarding emissions from contaminated sites. The present paper describes methods for obtaining quantitative estimates of SVOCs from soils based on flux chamber measurements, modeling, and ambient air measurements. On wet (i.e., H2O) soils, SVOCs at very low chemical loading levels on the adsorption sites (the so-called critical chemical concentration, critical loading, or saturation concentration) will behave, for volatilization purposes, as the pure-liquid substance would. For one soil, the PCB critical concentration was determined to be 775 ppm (95% confidence interval, 5.40E+02). Flux chamber-measured emissions from two contaminated sites were used and compared to model estimated values. The results agree reasonably well and indicate that the modeling approach used provided a conservative upper bound on the emissions. These approaches can be used to develop emissions estimates for SVOC-contaminated sites and inputs to air dispersion models.

Polybrominated diphenyl ethers in the sediments of the Great Lakes. 1. Lake Superior.

Sediment cores were taken in 2001 and 2002 in Lake Superior at six locations away from lakeshores and segmented at 0.5-5 cm intervals. The year of sediment deposition was estimated for each segment of four cores using the 210Pb dating technique. Samples were Soxhlet-extracted and cleaned up by silica gel fractionation, and the concentrations of 10 polybrominated diphenyl ethers (PBDEs) and 19 polychlorinated biphenyls (PCBs) were measured by GC-MS in SIM mode. In contrast to recent declining or level-off trends in PCB fluxes, the sedimentary records of PBDEs generally show a significant increase in recent years. The load of total PBDEs to Lake Superior was estimated to be 2-6 metric tons, and the current loading rate was about 80-160 kg yr(-1). With the exclusion of decabromodiphenyl ether (BDE209), the surficial concentration of sumPBDE (sum of 9 congeners) ranged from 0.5 to 3 ng g(-1), and the current sumPBDEs flux was 8-31 pg cm(-2) yr(-1). The concentrations of BDE209 were about an order of magnitude higher than the sum of other congeners, comprising 83-94% of the total PBDE inventory in the sediments. Among the other nine PBDEs detected, congeners 47 and 99 were the most abundant, and congeners 100, 153, 154, and 183 were also detected in all the cores. Congener analysis demonstrated that the pattern of PBDEs in Lake Superior sediments differs from those in air and fish.

The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study.

BACKGROUND: The risk of arterial injury with knee dislocation is well known. The most effective method for rapidly and accurately diagnosing arterial injury in this setting remains a topic of debate. Both physical examination and arteriography have been advocated, although each of these methods has its critics. The authors propose that the ankle-brachial index (ABI) can accurately predict whether patients with knee dislocations have sustained vascular injury. METHODS: A prospective study enrolled 38 patients with knee dislocation to evaluate for potential arterial injury using clinical pulse examination and ABI. Patients with an ABI lower than 0.90 underwent arteriography. Those with an ABI of 0.90 or higher were immobilized and admitted for serial examination and delayed arterial duplex evaluation. RESULTS: Of the 38 patients, 11 (29%) had an ABI lower than 0.90. All 11 had arterial injury requiring surgical treatment. The remaining 27 patients had an ABI of 0.90 or higher. None had vascular injury detectable by serial clinical examination or duplex ultrasonography. The sensitivity, specificity, and positive predictive value of an ABI lower than 0.90 were 100%. The negative predictive value of an ABI that reached 0.90 or higher was 100%. CONCLUSIONS: The ABI is a rapid, reliable, noninvasive tool for diagnosing vascular injury associated with knee dislocation. Routine arteriography for all patients with knee dislocation is not supported.

Soot deposition in the Great Lakes: implications for semi-volatile hydrophobic organic pollutant deposition.

Air deposition is a dominant transport mechanism for many hydrophobic organic pollutants (HOCs) to the Great Lakes. Our previous research has shown that soot exhibits large surface areas with high organic carbon contents suggesting the potential for strong HOC partitioning. As yet, however, clear data showing the link between HOCs such as PAHs to the deposition of soot into the Lakes (a proposed transport mechanism) is primarily inferential. We measured soot carbon (SC) and organic carbon (OC) in sediments collected from each of the Laurentian Great Lakes. OC and SC levels collected from locations near urban areas were higher than in sediments collected from distant locations. By far, Lake Superior had the lowest current SC flux of any lake, and Lakes Michigan and Erie had the highest. SC flux for all lakes had the following order: Superior < Huron < Ontario < Michigan < Erie, ranging 0.02-0.89 mg (m2 yr)(-1). Differences in lake size resulted in a different order for total SC loading by lake: Superior < Ontario < Huron < Erie < Michigan, ranging 2.3-420 x 10(3) tyr(-1). SC and PAH accumulation rates reported previously for Lake Michigan sediment were highly correlated; with a SC to PAH mass ratio of 10(4) (0.01%). The importance of soot as a potential sorbent for various classes of airborne HOCs was examined using a simple octanol-air partitioning model together with our previous characterization of soot particles. The results predict that both PAHs and PBDEs should have strong partitioning to soot and suggest the need to further investigate soot as a vector for PBDE transport.

Mortality after reamed intramedullary nailing of bilateral femur fractures.

We performed retrospective review of 743 patients treated with reamed intramedullary nailing of a femoral shaft fracture was done to assess the clinical impact of bilateral femur fractures on the mortality, hospital stay, and length of intensive care treatment in patients with blunt trauma. Unilateral injuries occurred in 689 patients and bilateral injuries occurred in 54 patients. Mortality in patients with bilateral femur fractures was 5.6% compared with 1.5% in patients with unilateral femur fractures. The two groups were analyzed using multiple linear regression and logistic regression with age and Injury Severity Scores as covariants to allow for comparison of similarly injured groups as predicted by the Injury Severity Scores. Bilateral femur fractures still were associated with a significantly higher mortality, longer length of stay in the hospital, and longer length of stay in the intensive care unit. As expected, when analyzed separately, patients with bilateral femur fractures had significantly higher Injury Severity Scores, longer lengths of stay in the intensive care unit, and longer lengths of stay in the hospital. Patients with bilateral femur fractures have an increased mortality when compared with patients with unilateral femur fractures after controlling for Injury Severity Score and age. When used alone, the Injury Severity Score underestimates the contribution of a second femur fracture.

Heterotopic ossification after knee dislocation: the predictive value of the injury severity score.

OBJECTIVE: To determine the relationship of multiple variables, including the Injury Severity Score (ISS), closed head injury (CHI), and timing and type of surgery to formation of motion-limiting heterotopic ossification (HO) following knee dislocation. DESIGN: Longitudinal observational study. SETTING: University level 1 trauma center. PATIENTS/PARTICIPANTS: Thirty-five consecutive patients with 36 knee dislocations (OTA fracture and dislocation classification 40-D) admitted over a 26-month period. MAIN OUTCOME MEASUREMENTS: Admission ISS, Glasgow Coma scale (GCS) scores, CHI, timing (> or < 3 weeks from injury) and type (open or arthroscopic) of surgery, number of cruciate ligaments reconstructed, medial surgical procedure, and eventual presence or absence of motion-limiting HO. RESULTS: A classification system for HO was developed ranging from none (type 0) to ankylosing (type IV) HO. Twenty-nine patients with type 0-III HO recovered an average range of motion of 126 degrees at an average of 14 months (group A). Six patients formed ankylosing type IV HO (group B). The ISS in group A ranged from 9 to 26. ISS in group B ranged from 26 to 50 (P < 0.001). Regarding the formation of type IV HO, the sensitivity of an ISS >/=26 was 100%, the specificity was 97%, and the positive predictive value was 86%. Patients in group B had a greater incidence of documented CHI (P < 0.025). Timing and type of surgery, number of ligaments reconstructed, and whether or not the patient had a medial surgical procedure had no statistical influence on degree of HO formation. CONCLUSIONS: An ISS of 26 seems to be a discrete boundary above which patients with knee dislocation are at extremely high risk for type IV HO formation if undergoing surgical reconstruction and below which patients are likely spared this complication. The presence of a CHI is a significant factor in type IV HO formation, although harder to quantify. None of the remaining independent variables studied were significantly related to ankylosing type IV HO formation.

Extensor mechanism-sparing paratricipital posterior approach to the distal humerus.

Adequate exposure of the articular surface of the distal humerus and elbow joint is required for operative stabilization of bicolumnar distal humerus fractures. The transolecranon approach, which provides complete posterior visualization and access to the distal humerus, is commonly used. Nevertheless, an olecranon osteotomy and other extensor mechanism-disrupting approaches have risks and possible complications. Alternative exposures have been described primarily for total elbow arthroplasty, but these involve extensive and potentially devascularizing dissections. In extra-articular (OTA type A) and simple articular distal humeral fractures with simple or multifragmentary metaphyseal involvement (OTA type C1 and C2), extensile approaches may not be necessary. For these fracture patterns, an alternative exposure is the extensor mechanism-sparing paratricipital posterior approach to the distal humerus through a midline posterior incision. This approach avoids an osteotomy and mobilizes the triceps and anconeus muscle off the posterior humerus and the intermuscular septae and provides adequate exposure for open reduction and internal fixation.

Successful reimplantation of a large segment of femoral shaft in a type IIIA open femur fracture: a case report.

Segmental bone loss associated with high-energy open fractures is a difficult problem. The more perplexing and controversial problem is that faced when the extruded segment of bone is retrieved from the field and available for potential reimplantation. Here we present successful reimplantation of a 13-cm segment of meta-diaphyseal femur in a 15-year-old boy. Successful reimplantation of the fragment was attributed to the anatomic location of the injury, meticulous wound care, multiple debridements, sterilization of the extruded fragment in chlorhexidine, and the patient's age.