Tissue expansion: a method to preserve bone length and joints following traumatic amputations of the leg--a follow-up of five legs amputated at different levels.

Tissue expansion of adjacent intact skin and subcutaneous tissue has in five legs provided high-quality soft-tissue coverage of the distal end in legs amputated at different levels without further shortening of the bone. The sensitivity of slowly expanded flaps is temporarily affected but eventually seems to return to normal. Expanded flaps have endured both sitting and the use of prostheses for 4 to 5 years. In one case the technique made it possible to save the knee joint. Besides being a functional reconstruction, the appearance of the reconstructed parts much improved. A technique of overexpansion and double flap coverage of the bone utilizing deepithelialization is described.

Closed treatment of Jones fracture. Good results in 40 cases after 11-26 years.

40 patients with transversal or short oblique fractures of the proximal shaft of the fifth metatarsal bone (Jones fracture) were treated with full weight bearing with or without elastic bandage in 39 cases and plaster cast immobilization in one. 24 cases were acute traumatic fractures, 14 stress fractures and 2 refractures. After 17 (11-26) years, 33 of the fractures had healed primarily, evidence of refracture or delayed union was found in 7 and there were no non-unions. All but one of the patients were free of symptoms.

Jones fracture. Surgical versus nonsurgical treatment.

Sixty-three patients with 66 transverse and short oblique fractures of the proximal shaft of the fifth metatarsal bone (Jones fracture) were evaluated an average of five years (range, one to ten years) after the injury. There were 27 acute fractures and 39 chronic, or stress, fractures. The primary treatment was surgical for one third of the injuries and nonsurgical for the others. Surgical treatment consisted of the insertion of medullary screws. Nonsurgical treatment consisted of the application of either a plaster cast or an elastic bandage. Almost one fourth of the fractures treated nonsurgically later had to be treated surgically because of delayed unions or refractures. Late surgery was required in 12% of acute fractures and in 50% of chronic fractures with sclerosis narrowing the medullary canal. Irrespective of the primary treatment, all the patients had full function at the time of the follow-up evaluation, and no nonunions were diagnosed.

Dislocations of the elbow and intraarticular fractures.

Of 23 patients with an elbow dislocation associated with at least one displaced fracture of the radial head, 19 patients had the radial head extirpated two days range, 0-16 days) after injury. In four elbows, redislocation occurred. All four redislocations were associated with a displaced fracture of the coronoid process. A follow-up examination was performed in 19 patients between three and 34 years after the injury. Severe osteoarthritis with reduced joint space developed in 12 elbows. Reduced range of motion was the most common complaint, and reduced extension was the most common finding. To lower the risk and prevent severe instability, the radial head should be preserved if possible. If the radial head must be resected, suturing of torn ligaments and muscles at the epicondyles is essential.

Ligamentous injuries in dislocations of the elbow joint.

The opinions concerning presence of instability and ligamentous injuries following dislocation of the elbow differ. Thirty-one patients with an elbow dislocation without concomitant fracture were examined under anesthesia for stability at an average time of two days after the injury. All elbows were unstable to valgus stress in the extended position compared with the healthy side. Eight elbows were unstable to varus stress. Nine elbows were easily redislocated in semiflexed position under anesthesia. Surgical exposure and ligament suture were performed medially in all cases and laterally in 18 cases. All the ligaments were completely ruptured or avulsed in the epicondyle attachment. In most cases the ligamentous ruptures were combined with rupture or avulsion of the muscular origins at the epicondyles. The degree of muscular damage was correlated with the tendency to redislocate under anesthesia.

Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study.

Thirty consecutive patients who had dislocation of the elbow without concomitant fracture and who were sixteen years old or more were examined under general anesthesia for stability of the joint at an average of four days after the injury. All of the elbows showed medial and sixteen showed both medial and lateral instability. The patients were then randomly assigned to undergo either non-surgical or surgical treatment of the ligamentous injuries. All of the surgically treated elbows showed complete rupture or avulsion of both the medial and lateral collateral ligaments, and in about half of these patients the muscle origins were found to be torn from the humeral epicondyles. At follow-up, both groups showed generally good results; the differences were not statistically significant. There was no evidence that the results of surgical repair of the ligaments were any better than those of non-surgical treatment.

Surgical versus nonsurgical treatment of ligamentous injuries following dislocations of the elbow joint.

Sixty-two patients older than 16 years of age at the time of injury were reexamined an average of five years (range, 1 to 12 years) after a dislocation of the elbow without concomitant fracture. Thirty-four were treated nonsurgically with closed reduction and immobilization in a plaster cast. Twenty-eight were treated surgically with primary ligament repair followed by immobilization in plaster. Ligament repair was performed medially in all cases and laterally in 17, on the average two days after injury. At follow-up examination, the most common complaint in both groups was limited range of motion, decreased extension being the most common. In no respect were the surgically treated elbows better than those treated nonsurgically. No evidence was found to recommend primary surgical treatment of ligament injuries associated with dislocation of the elbow.