Helmet hazards. Do's & don'ts of football helmet removal.

EMS providers must use extreme caution when evaluating and treating an unconscious football player, especially when the extent of the injury remains unknown. Suspect any unconscious football player has an accompanying spinal injury until proven otherwise. If the football player isn't breathing or the possibility of respiratory arrest exists, it's essential that certified athletic trainers and EMS providers work quickly and effectively to remove the face mask and administer care. In most situations, the helmet doesn't need to be removed in the field. Proper management of head and neck injuries includes leaving the helmet in place whenever possible, removing only the face mask from the helmet and developing a plan to manage head- and neck-injured football players using well-trained sports medicine and EMS providers. EMS agencies should work with their local high school or college athletic trainers to practice these removal techniques prior to the start of the football season.

Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group.

BACKGROUND: The purpose of the present study was to compare the rate of short-term wound complications associated with rotational flaps and that associated with free flaps for coverage of traumatic soft-tissue defects about the tibia. METHODS: Of 601 patients prospectively enrolled in a multicenter study of high-energy trauma of the lower extremity, 190 patients (195 limbs) required flap coverage and had six months of follow-up. The injury data included the ASIF/OTA classification of the tibial fracture and the soft-tissue injury and the functional status of the neurovascular and muscular structures of the soft-tissue compartments at the time of soft-tissue coverage. The treatment data consisted of the type of flap, the timing of the flap coverage, and the type of fixation. The patient characteristics that were recorded included the age, gender, presence of comorbidities, and smoking status at the time of the injury. Short-term complications included wound infection, wound necrosis, and loss of the flap within the first six months after the injury. RESULTS: Eighty-eight limbs were treated with a rotational flap, and 107 limbs were treated with a free flap. Overall, complications occurred after fifty-three (27 percent) of the 195 flap procedures; forty-six (87 percent) of the fifty-three required operative treatment. The two treatment groups were similar with respect to age, gender, comorbidities, preinjury smoking status, ASIF/OTA classification of the fracture, and prevalence of vascular injury requiring repair (p>0.05). There were two important differences between the two groups. First, three of the four leg compartments--that is, the anterior, lateral, and deep posterior compartments--were more likely to be functionally compromised in the free-flap group than in the rotational flap group (p<0.05), suggesting that patients in the free-flap group had sustained more severe soft-tissue injuries. Second, the Injury Severity Score was significantly higher (p = 0.001) in the rotational flap group (mean, 14 points) than in the free-flap group (mean, 11 points), suggesting that patients in the former group had sustained more substantial total body trauma. Overall, there were no significant differences between the two groups with respect to the complication rates. However, among those with the most severe grade of underlying osseous injury (an ASIF/OTA type-C injury), 44 percent of the limbs that were treated with a rotational flap had a wound complication compared with 23 percent of the limbs that were treated with a free flap (p = 0.10). To control for any differences between the two groups with respect to the severity of the injury, the treatment methods, or the patient characteristics, multivariate regression modeling was performed. An interaction effect between the type of flap and the severity of the underlying osseous injury demonstrated significance (p<0.05) after controlling for other factors. Of the limbs that sustained an ASIF/OTA type-C osseous injury, those that were treated with a rotational flap were 4.3 times more likely to have a wound complication requiring operative intervention than were those treated with a free flap. No significant difference in the rate of complications was detected with respect to the type of flap used for the limbs that had lower-grade osseous injuries. CONCLUSIONS: We found that use of a free flap to treat limbs with a severe underlying osseous injury was significantly less likely to lead to a wound complication requiring operative intervention than was use of a rotational flap.

External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics.

BACKGROUND: The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. We report on the use of EF as a temporary fracture fixation in a group of patients with multiple injuries and with femoral shaft fractures. METHODS: Retrospective review of charts and registry data of patients admitted to our Level 1 trauma center July of 1995 to June of 1998. Forty-three patients initially treated with EF of the femur were compared to 284 patients treated with primary IMN of the femur. RESULTS: Patients treated with EF had more severe injuries with significantly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treated with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe enough to require intracranial pressure monitoring. All 12 required therapy for intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindication to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time for EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes with an estimated blood loss of 400 mL. One patient died before IMN. One other patient with a mangled extremity was treated with amputation after EF. There was one complication of EF, i.e., bleeding around a pin site, which was self-limited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF followed by IMN had bone infection and another had acute hardware failure. CONCLUSION: EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed by IMN when the patient is stabilized. There were minimal orthopedic complications.

Reamed femoral nailing in patients with multiple injuries. Adverse effects of tourniquet use.

Limb reperfusion after tourniquet ischemia causes pulmonary microvascular injury. Similarly, microembolization, like that associated with reamed femoral nailing, can induce pulmonary microvascular injury. Both processes result in increased pulmonary capillary membrane permeability and edema. However, the association between femoral nailing followed by tourniquet ischemia and clinical lung injury has not been described. The authors reviewed 72 patients with femoral shaft fractures and tibial or ankle fractures requiring internal fixation between 1987 and 1993. All femoral shaft fractures were treated with reamed intramedullary nails. Patients were divided into groups, based on whether the tibial or ankle injury was managed surgically with (Group T, 34 patients) or without (Group NT, 38 patients) a tourniquet. Group T was subdivided based on tourniquet time: T1, less than or equal to 90 minutes; T2, greater than 90 minutes. Groups were matched for injury severity. Group NT had fewer ventilator dependent days and intensive care days than Group T (NT: ventilator dependent days, 2.5 +/- 5.2; intensive care days, 3.9 +/- 6.5; T: 5.1 +/- 6.4; intensive care days, 6.7 +/- 6.6). Ventilator dependent days and intensive care days increased with increasing tourniquet time (T1: ventilator dependent days, 3.2 +/- 3.6; intensive care days, 5.4 +/- 4.6; T2: ventilator dependent days, 7.5 +/- 8.5; intensive care days, 8.5 +/- 8.5), suggesting that in patients with multitrauma, combining reamed femoral nailing with fracture fixation under tourniquet control increases pulmonary morbidity. Further investigation to measure pulmonary injury associated with ischemia reperfusion and intramedullary nailing in patients with multitrauma is warranted.

Assessment of pelvic ring stability after injury. Indications for surgical stabilization.

The indications for surgical stabilization of pelvic ring injuries are based on an assessment of the extent of disruption of the pelvic ring and the associated deformity of the bony pelvis. The relevant anatomy and biomechanics or the pelvis, pelvic ring injury classifications, initial assessment, and emergent treatment of patients with pelvic ring injuries is reviewed, and a discussion or indications for surgical stabilization of pelvic ring disruptions is presented.

The effect of variable size posterior wall acetabular fractures on contact characteristics of the hip joint.

The indications for open reduction and internal fixation of posterior wall acetabular fractures associated with a clinically stable hip joint are unclear. In previous work a large posterior wall defect (27% articular surface area) resulted in significant alteration of load transmission across the hip; specifically, there was a transition from evenly distributed loading along the acetabular articular surface to loading concentrated mainly in the superior portion of the articular surface during simulated single leg stance. However, the majority of posterior wall fractures involve a smaller amount of the articular surface. Posterior wall acetabular fractures not associated with instability of the hip are commonly treated nonoperatively. This practice does not account for the size of the posterior wall fracture. To study the biomechanical consequences of variably sized articular defects, a laboratory experiment was conducted evaluating three progressively larger posterior wall defects of the acetabulum during simulated single leg stance using superlow Fuji prescale film (Itochu International, New York): (a) 1/3 articular surface width through a 50 degrees arc along the posterior wall of the acetabulum, (b) 2/3, and (c) 3/3 articular width defects through the same 50 degrees arc along the posterior wall of the acetabulum. In the intact acetabulum, 48% of the total articular contact was located in the superior acetabulum. Twenty-eight percent of articular contact was in the anterior wall region of the acetabulum and 24% in the posterior wall region. After the 1/3 width posterior wall defect, 64% of the articular contact was located in the superior acetabulum (p = 0.0011). The 2/3 width posterior wall defect resulted in 71% of articular contact area being located in the superior acetabulum (p = 0.0006). After the 3/3 width posterior wall defect, 77% of articular contact was located in the superior acetabulum, significantly greater than the intact condition (p < 0.0001) and 1/3 width defect (p = 0.0222). The total absolute contact areas for all defect conditions were significantly less than the intact conditions. The results of this study reconfirm the observation that posterior wall fractures of the acetabulum significantly alter the articular contact characteristics in the hip during single leg stance. The relationship between defect size and changes in joint contact showed that the smallest defect resulted in the greatest alteration in joint contact areas, whereas larger defects resulted in minor increments of change in contact area. This finding is of concern because the clinical practice of managing acetabular fractures nonoperatively if the hip joint is stable is based on the supposition that the joint retains enough integrity to function without undue risk of late posttraumatic osteoarthritis. A better understanding of the natural history of stable posterior wall acetabular fractures is needed to ascertain whether some of these fractures merit operative repair.

Removal of intramedullary nails from the femur: a review of 45 cases.

The excellent biocompatibility of titanium and its alloys may result in osseointegration. In order to determine if this presents an obstacle to removal of intramedullary nails, we retrospectively reviewed a series of 45 cases of isolated removal of a femoral nail. Indications for removal were persistent pain and discomfort, request of an asymptomatic patient, or skeletal immaturity. Twenty-three nails were titanium, and 22 were stainless steel. Although removal of the titanium nails had a significantly longer operative time (110 vs. 84 min), analysis of variance indicated that this was due to a greater number of crosslocking screws in the titanium nails (2.2 vs. 0.6) and a tendency to set the titanium nails deeper in the femur. The use of the titanium material per se did not pose a risk factor for difficulty in late removal of an intramedullary nail.

Spica cast treatment of femoral shaft fractures in children--the prognostic value of the mechanism of injury.

We reviewed the data on 47 closed femoral shaft fractures in 46 children 10 years of age or less treated by early closed reduction and spica cast immobilization from 1980 through 1988. These children were followed at least through the time of fracture union, spica cast removal, and onset of unprotected weight-bearing. Treatment was defined as being primarily by spica cast immobilization if less than 7 days of skin traction preceded closed reduction and cast application. The mean age at injury was 4.4 years (range, 0.2-9.9 years). Mechanisms of injury were identified and segregated into those involving high-energy and low-energy trauma. Twelve of 23 fractures (52%) caused by high energy required at least one repeat closed reduction or other treatment to correct excessive shortening or angulation that occurred following the initial reduction. Four children required prolonged skeletal traction before reapplication of a spica cast. In contrast, only 2 of 24 fractures (8%) caused by low-energy trauma required repeat closed reduction and none required skeletal traction. Whereas the mean age of the children sustaining high-energy trauma (6.1 years) was higher than that of children in the low-energy trauma group (2.9 years), 7 of 12 fractures caused by high energy that required repeat reduction occurred in children 7 years of age or less. Femoral shaft fractures in children caused by high energy are more likely to become displaced following closed reduction and early spica cast immobilization than fractures caused by low energy. These children require careful radiographic monitoring following this type of treatment to assess fracture alignment.

Successful intravenous immune globulin therapy for human immunodeficiency virus-associated thrombocytopenia.

High-dose intravenous (IV) immune globulin was used to treat human immunodeficiency virus (HIV)-associated thrombocytopenia four times in three patients. The average platelet count at initiation of therapy was 12 x 10(9)/L (12 x 10(3)/mm3), and the platelet count after therapy was 159 x 10(9)/L (159 x 10(3)/mm3), giving a mean increase of 147 x 10(9)/L (147 x 10(3)/mm3) (1225%). The conditions of two of these patients were refractory to corticosteroids, but giving IV immune globulin along with steroids appeared to enhance the response to IV immune globulin. A review of the literature revealed that 53 (88%) of 60 patients with HIV-associated thrombocytopenia responded to IV immune globulin with platelet counts greater than 50 x 10(9)/L (50 x 10(3)/mm3). We conclude that IV immune globulin therapy achieves transient elevations in platelet counts to levels that control bleeding and permit surgery in patients with severe, HIV-associated thrombocytopenia.