Treatment of comminuted distal radial fractures with preliminary horizontal finger trap traction and a Roger-Anderson external fixation device.

Over a five-year period, 43 patients with comminuted distal radial fractures were treated with a Roger-Anderson external fixation device after the fracture was aligned in Strong's horizontal finger trap traction. Nineteen patients (21 wrists) were available for personal interview and radiographic follow-up. A 0.5-mm loss of radial height and an average loss of 2.4 degrees of palmar angulation presented. Range of motion (ROM) was excellent, stiffness was nonexistent or minimal in 81%, pain was nonexistent or minimal in 86%, and weakness of grasp was nonexistent or minimal in 81%. Complications were minimal; they included three pin tract infections, two of which required pin removal before they resolved. One patient fractured a pin that also required removal. Strong's horizontal finger trap traction and the Roger-Anderson external fixation device simplified the sometimes difficult treatment of this fracture. It seems to be most effective in young athletic individuals who have good bone stock and very comminuted fractures.

Transdermal fentanyl for postoperative pain management. A double-blind placebo study.

A double-blind, placebo-controlled, randomized design was used to evaluate the safety and efficacy of transdermal fentanyl citrate for postoperative pain management in 42 healthy adult patients undergoing major shoulder surgery. Transdermal systems rated to deliver fentanyl citrate at a rate of 75 micrograms/h were applied to the skin immediately prior to surgery and worn for 24 hours. Patients in the active group required significantly less morphine than the placebo group during the 24-hour period that systems were in place (0.8 +/- 0.61 vs 1.3 +/- 0.64 mg/h) and for the first 12 hours after removal (0.3 +/- 0.36 vs 0.5 +/- 0.32 mg/h). The incidence of vomiting was more frequent in the active group than in the placebo group (73% vs 30%), and respiratory rate in the active group was lower than in the placebo group during the 13- to 24-hour interval of system application (14 +/- 3 vs 16 +/- 2 breaths per minute). Nevertheless, transdermal fentanyl appears to be safe and effective after orthopedic surgery in healthy adult patients.

Pain in home hospice patients: an exploratory descriptive study.

A descriptive, exploratory study was conducted to determine the prevalence, severity, and relationship of pain to the physical, psychological, social, and spiritual dimensions of hospice patients. From retrospective analysis of initial treatment plans, one hundred subjects were divided into a pain (N = 58) and a non-pain (N = 42) group. Group differences were determined through percentage and chi-square analysis of observed frequencies. Findings on the prevalence, severity, and presence of pain in far-advanced cancer were consistent with those previously reported. The pain group demonstrated significant differences in number of metastatic lesions, physical limitations, alterations in elimination, and alterations in nutrition. The number of subjects completing legal and funeral arrangements was significantly higher for the pain group.

Changing patterns in tibial fractures resulting from skiing.

Of the 734 adult tibial fractures treated in Aspen, Colorado, from 1968-1978, follow-up results were obtained on 527 (72%). The fractures were analyzed with regard to rate of healing, age of patient, and location of fractures. There was a statistically significant increase in healing time with increasing age between ages 16-40. The location of tibial fracture (proximal, middle, distal) had no significant influence on rate of healing. The occurrence of open tibial fracture was low (3% of total) and in most instances wounds were benign (Class I). Compartment syndrome is rarely encountered in skiing fracture because of the relatively low energy involved. All tibial fractures occurring between 1982-1984 were reviewed and compared to the earlier series. This comparison confirmed the continual overall decline in rate of tibial fracture from skiing (from 12.9/100,000 skier days in 1968 to 2.9/100,000 skier days in 1983). This decline was primarily in spiral fractures (from 70% of total in 1968 to 50% in 1983). The percent of transverse fractures was unchanged (+/- 15%) while the percent of short oblique fractures increased from 11% to 33%. Properly adjusted and maintained safety equipment afforded reasonable protection from spiral fractures of the tibia, but a conceptual departure from the current release binding design would be required to protect against the benign moments that produced transverse and short oblique fracture. The current treatment philosophy is based on fracture type and the availability or experience with newer treatment modes.

Acute surgical repair of the skier's thumb.

Complete ulnar collateral ligament tears incurred during the period fall 1977 through spring 1979 were treated under regional anesthesia by a single group of surgeons in an identical fashion as outpatients. Of 123 thumbs repaired, 69 (59%) were available for follow-up examination. There were 34 women and 35 men with an average age of 34.5 years (range, 16-61 years). The follow-up period averaged 31.6 months (range, 16-46 months). Weakness of pinch was described as none or mild in 66 (96%) and significant in only three (4%). Stiffness was described as none or mild in 66 (96%), moderate in two (3%), and severe in one (1%). Pain was described as none or mild in 68 (99%) and moderate in one (1%). Sixty-two patients (90%) preferred outpatient surgery with regional anesthesia whereas only seven (10%) did not. Forty-five (65%) of the 69 patients who required surgery had used traditional poles with straps, suggesting the pole as the causative factor. However, only 20% of noninjured skiers during the 1981-1982 season were using traditional poles with straps, and the total number of complete ulnar collateral ligament repairs did not decrease with the same number of skiers. Therefore, the change in pole design has not decreased the incidence of total ulnar collateral ligament tears. The results of acute surgical repair as an outpatient with regional anesthesia are excellent; 96% of the patients were pleased with the results. If the lesion is overlooked, the results of secondary construction are not nearly as good.

Tendon injuries about the ankle resulting from skiing.

In essence there are three afflictions about the ankle that result from skiing: rupture of the Achilles tendon, Achilles tendinitis, and dislocation of the peroneal tendon. The cause of Achilles tendinitis and Achilles tendon rupture is, in fact, pressure within the fascial compartment of the Achilles tendon, which is caused by a swollen distal soleus muscle, occluding the circulation, and thereby producing avascular necrosis with subsequent tendinitis yielding to rupture. Four types of peroneal tendon dislocations and related problems are presented.

Primary knee ligament repair--revisited.

There were 4710 knee sprains resulting from skiing in the four Aspen ski areas between 1976 and 1979. Twenty percent of the patients (942) had complete tears. Of these, 302 elected to remain in Aspen for treatment. All were treated by primary ligament repair without augmentation. These cases were evaluated an average of 42 months after injury. Patients with isolated tears of the medial collateral ligament were found to be doing well; virtually all of them had returned to preinjury activity levels. Thirty-six percent of the isolated anterior cruciate repairs were rated failures, and 43% of the combination ACL-MCL injuries had failed because of anterior cruciate deficiency. Twenty-nine percent of the ACL and ACL-MCL injuries had meniscal tears. Cases that included meniscectomy had a failure rate twice as great as those in which the meniscus was preserved. The results following repair of anterior cruciate tears were not acceptable, and augmentation was indicated. Primary repair of medial collateral ligament tears produced excellent results. Meniscal tears were frequent in association with ligament disruption. Ligament repairs were less satisfactory when meniscectomy was performed at the time of the repair.

The intramedullary compression rod.

The Kaessmann compression device was employed in 26 patients with fractures of the long bones. In 15 fractures of the tibia, prompt healing occurred, even in fractures in the distal one-fourth of the tibia. Most of these cases were treated without external plaster support, and were permitted early ambulation, with partial weight-bearing. The technique for immobilizing these fractures involves a sliding a Kuntscher nail over a tension rod, and then fixing the clevis of the tension rod to the distal bone fragments by a transverse screw. The Kuntscher nail is fixed to the proximal bone fragment by a metal lip, and after compression is achieved, a locking sleeve fixed by a screw to the tension rod, prevents loss of compression. In 11 cases of pseudarthrosis of the tibia, the medullary canal was enlarged by passing graduated drills down the bony canal, over a guide wire. The compression rod was then inserted across the pseudarthrosis, and seventy to 80 kg/cm2 pressure was applied to the bone ends. No bone grafting procedure was performed. In all 11 cases, prompt union occurred. Postoperative management was similar to that employed in the treatment of fresh fractures. Three success fusions of the ankle also attest to the effectiveness of this immobilization. Although controversy exists regarding the role of compression in the healing of fractures, the axial compression rod does overcome distraction, compresses the bony surfaces, immobilizing them securely to produce union with an economy of callus.