What are the risk factors for complications after combined injury of the pelvic ring and acetabulum?

PURPOSE: Combined acetabular and pelvic ring injuries represent a unique subset of pelvic trauma and little is known regarding their complications and outcomes. We sought to further evaluate these injury patterns and quantify their outcomes. METHODS: A retrospective review at a single level 1 trauma center was performed on all patients with operatively treated combined ring and acetabulum injuries during a seven-year period. Main outcome measurements include all-cause complication including residual neurologic deficit, deep infection, conversion to total hip arthroplasty, deep venous thrombosis and mortality. RESULTS: Seventy operatively treated combined ring and acetabulum patients with one-year follow-up were reviewed. The overall complication rate was 44%. Hip dislocation occurred in 40% of the cohort and was significantly associated with residual neurologic deficit and all-cause complication. Angiography with embolization was not associated with an increased rate of deep infection. Open acetabular approaches had a significantly higher complication rate compared to percutaneous procedures. Delay to definitive fixation greater than 36 h trended toward but did not reach association with all complications. CONCLUSION: Combined injuries to the acetabulum and pelvic ring have high rates of complications. No individual fracture patterns were identified as risk factors, but hip dislocation was associated with an increased rate of complications. When possible, percutaneous reduction and fixation of acetabular fractures and early definitive fracture fixation lead to lower rates of complications. Use of angiography with embolization appears to be safe and does not increase the risk of infection or other complications.

Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients.

BACKGROUND: From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This two-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing. METHODS: Fifty-four multiply injured patients with a total of fifty-nine fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis. RESULTS: The average Injury Severity Score for the fifty-four patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four) had additional orthopaedic injuries (average, three; range, zero to eight), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common. Forty fractures were closed, and nineteen fractures were open. According to the system of Gustilo and Anderson, three of the open fractures were type II, eight were type IIIA, and eight were type IIIC. Intramedullary nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight. All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury; the average duration of the procedure was thirty minutes. The duration of external fixation averaged seven days (range, one to forty-nine days) before the fixation with the static interlocked intramedullary nail. Forty-nine of the nailing procedures were antegrade, and ten were retrograde. For fifty-five of the fifty-nine fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure. The other four fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of ten days (range, eight to fifteen days) after fixator removal and before intramedullary nailing. Follow-up averaged twelve months (range, six to eighty-seven months). Of the fifty-eight fractures available for follow-up until union, fifty-six (97 percent) healed within six months. There were three major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing. The infection rate was 1.7 percent. Four other patients required a minor reoperation: two were managed with manipulation under anesthesia because of knee stiffness, and two underwent derotation and relocking of the nail because of rotational malalignment. The rate of unplanned reoperations was 11 percent. The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees). CONCLUSIONS: We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.

Optimal position for plate fixation of complex fractures of the proximal radius: a cadaver study.

OBJECTIVE: To determine the optimal postion for plate fixation in complex fractures of the proximal radius in which head and neck dissociation occurs. DESIGN: Technical study. SETTING: Tertiary referral center, teaching hospital, U.S. military. SUBJECTS: Five preserved cadavers. MAIN OUTCOME MEASURE: Radioulnar impingement and proximity to neurovascular structures were directly measured in elbows plated in each of three positions: neutral, full pronation, and full supination. RESULTS: Application of the 2.0-millimeter T-plate to the lateral aspect of the radial head and neck with the forearm in neutral position had no impingement, whereas application in full pronation resulted in loss of the last 30 degrees of supination. Plate application in full supination resulted in the loss of the last 10 degrees of pronation. In addition, there was no impingement when the 2.7-millimeter plate was applied similarily in the neutral position. None of these positions resulted in increased risk to neurovascular structures. CONCLUSIONS: The optimal position for plate fixation of complex proximal radius fractures is with the forearm in neutral position, with the plate applied directly lateral. A larger implant, 2.7 millimeters, may be used if this technique is followed without further risk of impingement and loss of motion.

Immediate interlocking nailing of fractures of the femur caused by low- to mid-velocity gunshots.

A retrospective review of 39 fractures of the femur in 37 patients caused by low- and mid-velocity handgun missiles treated with static interlocking nailing within 18 h of injury was conducted to evaluate the efficacy, safety, and cost savings of immediate intramedullary nailing in these injuries. Patients were followed through union of the fracture with an average follow-up of 12.5 months. The average hospitalization was 8.5 days. All but two fractures healed in an average of 14 weeks (range 8-28). One delayed union was treated with exchange intramedullary nailing with reaming 5 months postinjury and progressed uneventfully to fracture union. One nonunion occurred, presenting with broken distal interlocking screws 18 months after injury, which was treated with an exchange intramedullary nailing with reaming. The nonunion healed within 4 months of this secondary procedure. There were no malunions of > 5 degrees angulation, no leg length discrepancies of > 1.0 cm, and no rotational malalignments noted. There was one (2.5%) infection that was successfully treated with nail removal, reaming of the canal, and reinsertion of a larger diameter nail. We conclude that immediate interlocking nailing of low- and mid-velocity gunshot fractures of the femur is an effective and safe treatment. Compared with previously published data on intramedullary nailing of femoral gunshot fractures, immediate intramedullary nailing resulted in a shorter hospital stay with a significant decrease in hospital expenses. Because the findings of this study indicate that early fixation in these injuries had no detrimental effect on the clinical results, we recommend immediate intramedullary nailing of gunshot fractures of the femur.