Closed flexible intramedullary nailing of adolescent femoral shaft fractures.

Twenty-five femoral shaft fractures in twenty-three patients aged 10-16 years with open epiphyses and treated with flexible intramedullary nailing were studied retrospectively. Clinical and roentgenographic follow-up averaged 28 months. Hospitalization, which included patients with multiple injuries, averaged 11.7 days. Patients ambulated without assist devices as early as 2 weeks postoperatively (average of 7.7 weeks). All fractures healed with no leg length inequality--21 with anatomic alignment and full range of motion of the hip and knee. Three patients sustained intraoperative extension of the fracture resulting in healing with angular or rotatory malalignment. One patient with associated knee ligamentous injury had less than full knee flexion at follow-up. All patients had normal gait (except one patient with residual hemiplegia) and were able to participate in full activities including athletics. Early ambulation and functional recovery with low morbidity and cost suggest that this procedure should be considered for the treatment of femoral shaft fractures in this age group.

The ring butterfly fragment in diaphyseal fractures: its importance in flexible intramedullary nailing.

Ring butterfly fragment was described after it was noted to pose problems during insertion of flexible intramedullary nails. This fragment contains the entire circumference of the medullary canal or a substantial part of it. Once recognized preoperatively the fragment is reduced, providing a stable fracture configuration for fixation with flexible intramedullary nails. If the fragment is left displaced, it may lead to nonunion of the fracture; particularly after flexible intramedullary nailing of the tibia.

Ender nailing of acute fractures of the humerus. A study of closed fixation by intramedullary nails without reaming.

A prospective study of closed intramedullary fixation of fractures of the shaft of the humerus, using Ender nails, was performed over a six-year period. Eighty-nine fractures in eighty-eight patients were treated with no immobilization postoperatively. Three patients were lost to follow-up. Eighty-five of the remaining eighty-six fractures healed, the average time to clinical union being 7.2 weeks. Non-union of one fracture occurred and there were no infections or malunions. Six of the nine preoperative and two postoperative radial-nerve palsies were lesions in continuity and healed spontaneously. The remaining three radial nerves that had been severed by a missile needed further attention. One of the nails backed out in eight patients, requiring revision in five. The average lack of complete extension of the elbow was 4 degrees and flexion of the elbow was 132 degrees. Abduction of the shoulder averaged 91 degrees; external rotation, 54 degrees; and internal rotation, 68 degrees. We conclude that closed intramedullary Ender nailing can be performed safely and effectively in selected fractures of the humeral shaft. However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment.

Locked flexible intramedullary nails in treatment of unstable femoral fractures.

Twenty patients with unstable femoral fractures were treated with distally locked flexible intramedullary nails. We present our surgical technique and our results. The method has the following advantages: it prevents rotational malalignment and shortening, it is a closed procedure, no reaming is necessary, there is no increase in c-arm time, and there is minimal increase in operative time. Locked flexible intramedullary nails should be used in patients with unstable femoral fractures who have dense metaphyseal bone. Osteopoenia is a contraindication to this method as it increases the risk of nail penetration into the hip.

Flexible intramedullary nailing of femoral shaft fractures.

Simple flexible intramedullary nailing is a suitable method of fixation of femoral shaft fractures with stable configurations. Complications are rare when nailing is properly executed, and patients are able to ambulate and bear weight within days of surgery. Problems arise when simple nailing is used to fix femoral shaft fractures with unstable configurations. Sliding of nails out of portals, loss of fixation, malrotation, and knee pain often result. Therefore, adjunctive measures must be used in the fixation of unstable fractures. The technique of nailing is demanding. The surgeon must be familiar with the principles of intramedullary nailing and should observe several procedures before attempting to do one alone. Furthermore, it is advisable to start with simple nailing of fractures with stable configurations to gain experience and confidence before undertaking a more complex procedure in a fracture with an unstable configuration. Finally, it must be emphasized that the principles of intramedullary nailing are essentially the same for all intramedullary devices. It must be also emphasized that there is little room for fast, temporary nailings and that there is no substitute for solid, precise fixation. There is no difference between quick insertion of a Küntscher-type rigid nail without reaming and speedy flexible nailing--both are fast and both will result in failure of fixation. The surgeon should resist the temptation to do fast procedures.

Pseudomonas aeruginosa bone and joint infection in drug abusers.

Thirty-nine sites of Pseudomonas aeruginosa bone and joint infection in thirty-five intravenous drug abusers were treated over a four-year period. Early diagnosis was based on a history of drug abuse and demonstration of the site of infection by a technetium bone scan. Most patients responded to long-term therapy with intravenous aminoglycoside and carbenicillin. Extensive early surgical procedures were rarely indicated except in patients with infection of a large synovial joint.

The isolated fracture of the ulnar shaft. Treatment without immobilization.

The isolated fracture of the ulnar shaft is notorious for prolonged healing time. Over a twenty-seven-month period, seventy-one such fractures were treated at our institution. The initial twelve fractures were immobilized with the standard axilla-to-palm plaster cast. They had an average healing time of 10.5 weeks and a non-union rate of 8 per cent. The remaining fifty-nine fractures were treated without a cast or with a cast or splint for no longer than two weeks after injury and then mobilization as tolerated. In this group the average healing time was 6.7 weeks and there were no non-unions. The motion at the wrist and elbow was always regained, and the average loss of forearm rotation was 5 degrees.

Flexible intramedullary nailing of tibial-shaft fractures.

Closed flexible intramedullary nailing was used in 38 fractures of the tibia shaft. Simple transverse, oblique, or spiral fractures were shown to be stable after nailing. Fractures with a large unicortical butterfly fragment, involving more than one-third of the cortex, had a tendency to angulate. There were 23 fractures in the distal third of the tibial shaft; nine in the middle third; and four in the proximal third. The operations were simple and quick, lasting an average of 38 minutes. Sixteen patients used a short walking cast, usually for periods of four to six weeks. The cast was usually applied for comfort. The average healing time was 14.3 weeks. There were three cases of delayed and nonunion. In one patient, significant increase in valgus deformity occurred and required a renailing procedure. There was one case of osteomyelitis in a patient who had a Grade 3 open tibial fracture, which was debrided with a considerable delay.

Adjunctive fixation in flexible intramedullary nailing of femoral fractures: a study of twenty-six cases.

Flexible intramedullary nailing has been shown previously to be an effective method of fixation of simple transverse fractures and those with unicortical comminution. Long oblique fractures and those with bicortical comminution had a tendency to shorten after simple nailing, usually requiring additional measures to prevent it. Preliminary cerclage wiring of long oblique components, screw fixation of supracondylar fragments, and limited plating of very comminuted cortex were successfully performed in 22 cases, and external fixation was successful following nailing in four cases of highly comminuted fractures. Adjunctive fixation in these cases could not itself provide stability at the fracture site, but simply converted an unstable fracture to a stable one; flexible intramedullary nailing provided further necessary fixation until the fracture healed, while allowing the patient's early mobility and ambulation.

Infected late false aneurysm of the deep femoral artery.

A false aneurysm may mimic an abscess, but concomitant existence of the two lesions seems not to have been previously described. In a 32-year-old man, a false aneurysm of the deep femoral artery was found to be in communication with an abscess cavity in the posterolateral thigh. The false aneurysm was found in the proximity of the protruding tip of a Steinmann pin which had eroded the arterial wall. The abscess was a consequence of posttraumatic and postoperative osteomyelitis which had been previously debrided, bone grafted, and immobilize with an external fixator attached to four Steinmann pins. The condition was successfully treated by surgical drainage of te abscess cavity, excision of the false aneurysm, and ligation of the deep femoral artery.

Development of maduromycosis (Madurella mycetomi) after nailing of a closed tibial fracture: a case report.

Maduromycosis is a rare fungal infection in the northern United States, most frequently caused by Allescheria boydii, usually in debilitated or immunosuppressed patients. An 18-year-old Mexican-American, in excellent health, developed multiple draining sinuses at the sites of insertion of Ender nails for a closed tibial fracture. Madurella mycetomi was cultured from black granules in a biopsy specimen. The source of fungal infection remained unknown, although it probably did not occur during the surgical procedure. Since no specific antibiotic treatment is available, it is possible that with progression of the infection, amputation may be necessary in the future.

Tetanus in a patient with frostbite: a case report.

Tetanus occurs in all ages, it can be associated with puncture wounds, war injuries, burns, ear infections, umbilical stump and post partum infections, and heroin abuse.5 Recently, we treated a patient who developed tetanus following frostbite of both feet. The patient had been previously immunized against tetanus, and was receiving antibiotics when the disease became manifest.