Investigation of how different halos influence pin forces.

STUDY DESIGN: This study investigated the effect of the size and material of halo rings on the pin force produced at the halo pin-calvarium complex. SUMMARY OF BACKGROUND DATA: Loosening of halo pins has been a problem with using the halo-vest apparatus to stabilize cervical spine fractures. METHODS: One standard halo pin and seven different halo rings were used to test the anterior pin hole of each ring at a constant torque of 8 inch-pounds (0.9 Nm). RESULTS: Pin force fluctuated from halo to halo, and decreased as the nut was tightened. CONCLUSIONS: Identical torques applied to different halos will not guarantee the same magnitude of pin force for halo fixation.

Spinal mobility and deformity after Harrington rod stabilization and limited arthrodesis of thoracolumbar fractures.

The results were reviewed for thirty patients in whom a thoracolumbar fracture had been treated with a Harrington rod placed three segments cephalad and two or three segments caudad to the injured vertebra and a short arthrodesis with removal of the Harrington rod after at least twelve months. The patients were evaluated with clinical examinations, lateral radiographs made with the spine in flexion and extension, and questionnaires at a median of thirty-two months after the stabilization. All of the arthrodeses were successful. The twenty patients who had a burst or compression fracture and who had posterior instrumentation lost only an average of 9 degrees of sagittal correction before attaining a solid fusion. For all thirty patients, the average motion in the sagittal plane at the vertebrae that had been spanned by the Harrington rod but not included in the arthrodesis ranged from 9 degrees at the third and fourth lumbar level to 2 degrees at the eighth and ninth thoracic level. The average total motion between five vertebrae that had been spanned by the rod but did not have an arthrodesis was 24 degrees; between four vertebrae, 23 degrees; and between three vertebrae, 19 degrees. In this series of thoracolumbar fractures treated with a longer Harrington rod than needed to span the level of the arthrodesis and a short arthrodesis, there was a documented return of motion to segments that had been previously spanned by the instrumentation but not included in the arthrodesis and good or excellent functional results over-all.

Thrombosis in spinal cord injury.

Some traditional coagulation assays and several new molecular markers of hemostatic activation were measured in 37 patients with spinal cord injury (SCI). Twenty one of the patients (57%) developed deep vein thrombosis (DVT). The radiofibrinogen uptake test (RFUT) was used to diagnose DVT. Thirty eight percent of quadriplegic and 88% of paraplegic patients developed DVT (p < 0.005). No significant differences were found in platelet counts, mean platelet volumes, fibrinogen levels, von Willebrand factor (Ag) levels, platelet factor 4 and beta thromboglobulin concentrations between the groups with and without DVT. Fibrinopeptide A, thrombin/antithrombin III (TAT) complexes and plasma D-dimer levels were significantly higher in the patients with thrombosis. Most patients with DVT had elevated TAT complex levels up to three days before the RFUT became positive. D-dimer levels were highest after the diagnosis had been made.

Failure of halo vest to prevent in vivo motion in patients with injured cervical spines.

Forty-two patients with cervical spine injuries immobilized in halo vests were studied prospectively to determine in vivo vertebral segmental motion. Lateral radiographs taken in the supine and upright positions within 5 days of injury demonstrated intervertebral motion. At noninjured levels, the positional change accounted for an average 3.9 degrees of angulation with the greatest motion occurring between the occiput and C1 (8.0 degrees). At the injured levels, sagittal plane angulation averaged 7.0 degrees and translation averaged 1.7 mm between the two positions. Fracture site motion did not correlate with either the fracture type or the injury level. Fracture site motion greater than 3 degrees of angulation or 1 mm of translation was observed at 35 (77%) of 45 injured levels. When treating patients who have unstable cervical injuries with halo vests, supine and upright radiographs should be obtained. If excessive motion is present, alternative methods of treatment should be considered.

Cervical osteomyelitis due to i.v. heroin use: radiologic findings in 14 patients.

We reviewed the radiographs of 14 patients who had cervical osteomyelitis and were IV heroin users. Eleven were men and three were women. Their age range was 33-48 years (mean, 39 years). Eleven regularly used the jugular vein access, and three alternated between the jugular and femoral veins. Initial radiographs of the cervical spine in 13 patients showed destruction of two or more vertebral bodies and the adjacent intervertebral disk, as well as a prevertebral soft-tissue mass. In one patient, findings on initial radiographs were normal, but marked destruction at two contiguous intervertebral levels and a large prevertebral abscess were identified 2 weeks later. All the patients had positive results on cultures of joint aspirates or bone biopsy materials (10 patients) or blood (four patients). Ten grew Staphylococcus aureus; two, Staphylococcus epidermidis; one, Streptococcus viridans; and one, Pseudomonas aeruginosa. CT in nine patients showed inflammatory reaction adjacent to the carotid sheath resulting from the repeated jugular injections and delineated the extent of prevertebral abscess and bone destruction. Scintigrams were of minimal value in establishing the diagnosis. Advanced vertebral body destruction, disk space infection, prevertebral abscess, and anterior cervical inflammatory reaction appear to be typical findings on radiographs in heroin abusers with cervical osteomyelitis.

Nutritional support: a prophylaxis against stress bleeding after spinal cord injury.

The incidence of upper gastrointestinal (UGI) bleeding and the effect of nutritional support was studied retrospectively in 166 spinal cord injured patients. Sixty six patients included in group 1 were started on oral diet when 'clinically ready' which resulted in a haphazard manner for provision of nutrition. One hundred patients in group 2 were treated according to an organised nutrition protocol. The protocol initiates total parental nutrition (TPN) if the patient is not tolerating an oral diet by day 5. All group 2 patients met their total energy requirements (TER) within 48 hours after initiating caloric supplementation. The overall incidence of acute acid peptic ulceration leading to significant bleeding or perforation was 4%. Five of the 66 group 1 patients (7.5%) and 2 of the 100 group 2 patients (2%) developed acute ulcerations. While the exact mechanism remains unclear, this significant (p less than 0.05) reduction indicates that a nutritional regimen that meets a patients TER decreases the likelihood of acid peptic complications after spinal cord injury.

Posterior tibial tendon rupture in pronation-external rotation ankle fractures.

We have recently treated two patients with closed pronation-external rotation bimalleolar ankle fractures. During the surgical explorations, an avulsion type rupture of the posterior tibial tendon was observed. Open reduction and internal fixation of the fracture in conjunction with primary tendon repair has produced excellent clinical results. We wish to report these two cases of this uncommon injury. More important, we wish to point out the association of the tendon rupture in conjunction with a particular type of fracture pattern.

Prophylactic femoral stabilization with the Zickel nail by closed technique.

From 1974 to 1983, forty-three femora in forty patients with metastases to the subtrochanteric area were stabilized using a Zickel subtrochanteric device. Thirty-five patients with thirty-eight stabilized femora could be evaluated at follow-up times ranging from thirty-seven days to five years and one month. In twenty-eight of the thirty-eight femora, a modified technique for insertion of the device had been used. Twenty-eight (80 per cent) of the patients were able to walk after an average of 3.8 days. No patient who had been able to walk preoperatively lost that ability. The average length of survival was 312 days postoperatively. Fifteen patients survived for at least fifteen months and five patients, with an average length of survival of 1276 days, were still alive at the time when this review was initiated. Complications included four perioperative deaths, one non-fatal pulmonary embolus, and five intraoperative technical complications--four of them occurring before the described modification of the technique was instituted. There were no infections and no failures of the device. No patient had a loss of stability after Zickel nailing. The modification of the technique allows safer introduction of the intramedullary nail into the weakened but intact femur by a closed method.

Is immobilization adequate treatment of unstable burst fractures of the atlas? A case report with long-term follow-up evaluation.

The biomechanics and roentgenographic anatomy of the unstable burst fracture of the atlas are well known. A few reports in the literature depict a bony avulsion of the transverse ligament associated with this fracture. However, all patients were treated surgically, so the natural course of this injury is undocumented--in other words, it is not known if the bony avulsion will heal. This is a case report of a 38-year-old woman with burst fracture of the atlas associated with a bony avulsion of the transverse ligament treated nonsurgically. At follow-up examination three years later, the bony fragment had not healed, and atlantoaxial instability persisted. Nonsurgical treatment of this injury may have a role, but surgical stabilization will usually be required after the posterior arch heals.

Ectopic calcification as a late sequela of compartment syndrome. Report of two cases.

Ectopic calcification occurred in two patients as a late sequela of compartment syndrome. The clinical and roentgenographic appearance are sufficiently typical that the diagnosis should be made without difficulty. Leaving the wound open after incision and drainage of these lesions may lead to secondary infection. Closing the wound after decompression over suction drainage or needle decompression are treatment alternatives that may lead to more satisfactory results.

Fractures of the femur secondary to low-velocity gunshot wounds.

Forty-three fractures of the shaft of the femur secondary to low-velocity gunshot wounds were evaluated to determine healing time, fracture alignment after healing, complications, and fracture characteristics. This study confirmed the previous reports of low infection rates and the need for minimal debridement for such fractures. The healing time was faster than that of closed fractures treated by similar means: the average healing time was 144.3 days. Alignment was easy to obtain and maintain, the average angular deformity being 5 degree or less with no rotational deformities. Three characteristic fracture types were noted: the double butterfly configuration of the shaft of the femur, the drill-hole fracture of the distal third of the femur as previously described experimentally, and a third type of fracture with an incomplete fracture secondary to the gunshot wound which acted as a stress riser with a resultant spiral fracture either proximal or distal to the impact site.

Deyerle fixation for intracapsular fractures of the femoral neck.

The results of the Deyerle method of pin plate fixation for intracapsular fracture of the neck of the femur are less satisfactory than the results in the original literature. We treated 143 intrascapsular neck fractures of the femur by the Deyerle method during the period from 1969 to 1975. Seventy-four patients had follow-ups of one year or had a major complication leading to failure prior to one year for evaluation. The failures were the result of avascular necrosis in 17.6% of the patients, non-union in 27% of the patients, and pin breakage in 1.35% of patients. Eight cases with combined avascular necrosis and non-union resulted in an overall failure rate of 26 patients or 35% of the 74 patients. These observations corroborate other reports in the literature on a high failure rate with multiple pin and plate fixation.

Clinical review of cervical spine injuries in children.

Clinical presentation is made of 18 cervical fractures occurring in children age 15 and under. Seven of 18 patients sustained neurological complications. The incidence of childhood cervical spine injury increases with age. Sixteen of 18 lesions were found in the C1 through C4 area in contrast to a greater involvement in adults in levels of C4 through C7. Although normal variations and anomalies are frequent in cervical spines in children, over treatment, at least initially, is recommended in all cases in which the diagnosis is in doubt.

Prophylactic internal fixation of the femur for neoplastic lesions.

Prophylactic intramedullary nailing was performed in eighteen femora of fourteen patients who had neoplastic lesions in the femur and survived for from thirty-eight to 1309 days after nailing. The procedure enabled all but three patients to be ambulatory with a walker by four days after operation and to continue to walk until they became moribund shortly before death. The complications were: one postoperative infection, penetration of the nail through the femoral cortex in three femora before prebending of the nail became part of the procedure, and ectopic bone about the proximal end of the rod. The procedure is recommended for the prevention of pathological fracture and relief of pain.