The effect of coronal plane angulation on patient reported outcome measures of operatively treated distal femur fractures: A multi-center prospective evaluation.

OBJECTIVES: The goal of this trial was to determine whether coronal plane angulation affects functional and clinical outcomes after the fixation of distal femur fractures. DESIGN: Multicenter, randomized controlled trial SETTING: 20 academic trauma centers PATIENTS/PARTICIPANTS: 156 patients with distal femur fractures were enrolled. 123 patients were followed 12 months. There was clinical outcome data available for 105 patients at 3 months, 95 patients at 6 months and 81 patients at one year. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing MAIN OUTCOME MEASUREMENTS: Radiographic alignment, functional scoring including SMFA, Bother Index, and EQ-5D. Clinical scoring of walking ability, need for ambulatory support and ability to manage stairs. RESULTS: At 3 months, there was no difference between groups (varus, neutral or valgus) with respect to any of the clinical functional outcome scores measured. At 6 months, compared to those with neutral alignment, patients with varus angulation had a worse Stair Climbing score (4.33 vs. 2.91, p = 0.05). At 12 months, the average patient with neutral or valgus alignment needed less ambulatory support than the average patient in varus. Walking distance ability was no different between the groups at any time point. With respect to the validated patient-based outcome scores, we found no statistical difference in in the SMFA, Bother, or EQ-5D between patients with valgus or varus mal-alignment and those with neutral alignment at any time point (p > 0.05). Regardless of coronal angulation, the SMFA trended towards lower (improved) scores over time, while EQ-5D scores for patients with varus angulation did not improve over time. CONCLUSIONS: Valgus angulation and neutral angulation may be better tolerated in terms of clinical outcomes like stair climbing and need for ambulatory support than varus angulation, though patient reported outcome measures like the SMFA, Bother Index and EQ-5D show no statistical significance. Most patients with distal femur fractures tend to improve during the first year after injury but many remain significantly affected at 12 months post injury.

Indications and anatomic landmarks for the application of lower extremity traction: a review.

PURPOSE: Fractures of the lower extremity, particularly of the femur and acetabulum, may be difficult to immobilize with splinting alone. These injuries may be best stabilized with the application of various types of skeletal traction. Often, traction is applied percutaneously in an emergent setting, making the knowledge of both superficial and deep anatomy crucial to successful placement. METHODS: Review was performed via PubMed search as well as referencing the Orthopaedic literature. Relevant articles to the anatomy of the knee, ankle and calcaneus as they pertain to traction placement were referenced in compiling the optimal recommendations for traction placement. CONCLUSION: By palpating and marking superficial landmarks and observing specific anatomic relationships, safe application of traction pins can be performed while minimizing iatrogenic injury to vital anatomic structures, and avoiding intra-articular placement which could potentially lead to joint infection.

Blast trauma: the fourth weapon of mass destruction.

Injury from blast is becoming more common in the non-military population. This is primarily a result of an increase in politically motivated bombings within the civilian sector. Explosions unrelated to terrorism may also occur in the industrial setting. Civilian physicians and surgeons need to have an understanding of the pathomechanics and physiology of blast injury and to recognize the hallmarks of severity in order to increase survivorship. Because victims may be transported rapidly to the hospital, occult injury to gas and fluid containing organs (particularly the ears, bowel and lungs) may go unrecognized. Information surrounding the physical environment of the explosion (whether inside or outside, underwater, associated building collapse, etc) will prove useful. Most of the immediate deaths are caused by primary blast injury from the primary blast wave, but secondary blast injury from flying debris can also be lethal and involve a much wider radius. Liberal use of X-ray examination in areas of skin punctures will help to identify a need for exploration and/or foreign body removal. Biologic serum markers may have a role in identifying victims of primary blast injury and assist in monitoring their clinical progress. Tertiary blast injury results from the airborne propulsion of the victim by the shockwave and is a source of additional blunt head and torso trauma as well as fractures. Miscellaneous (quaternary) blast injury include thermal or dust inhalation exposure as well as crush and compartment syndromes from building collapse. Any explosion has the potential to be associated with nuclear, biologic or chemical contaminants, and this should remain a consideration for healthcare givers until proven otherwise.

Orthopaedic trauma education: visions for the future through the OTA. Orthopaedic Trauma Association.

As the trauma center system continues to expand, not only will the requirement for more and better trained trauma surgeons increase, but the means of educating them will need to become more standardized. The general surgeons recognized this many years ago, but orthopaedic trauma has lagged in its efforts to present a coordinated academic and clinical program to residents and fellows. The Orthopaedic Trauma Association has made a move to develop guidelines which may be used by training programs in an effort to improve the educational standards of this subspecialty. The recruitment and retention of young orthopaedic trauma surgeons remains an issue.

Aggressive treatment of 119 open fracture wounds.

BACKGROUND: The purpose of this study was to determine whether immediate primary closure of open fracture wounds can be performed without increasing the incidence of infections and delayed unions/nonunions. Although the traditional management of these injuries has been open treatment, a trend toward immediate primary closure has evolved on our service. METHODS: All open fractures presenting to an urban Level I trauma center during a 42-month period were reviewed. Of the 127 patients with open fractures, 90 patients (119 open fractures) were initially treated at the above institution within 24 hours of injury, had fractures proximal to the carpus or tarsals, and were followed-up until fracture union. All patients underwent emergent wound irrigation and debridement. The method of fracture immobilization and timing of wound closure was left to the discretion of the attending orthopedic surgeon. Immediate primary closure was used in 22 of 25 Grade I open fractures (88%), 37 of 43 Grade II fractures (86%), 24 of 32 Grade IIIa fractures (75%), 4 of 12 Grade IIIb fractures (33%), and 0 of 7 Grade IIIc fractures (0%). RESULTS: Eight fractures (7%) were complicated by a deep wound infection/osteomyelitis, and 19 fractures (16%) developed a delayed union/nonunion. Statistical analysis revealed no significant difference in delayed/nonunion and infection rates between immediate and delayed closures. CONCLUSION: Immediate primary closure of open fracture wounds after a thorough debridement by an experienced fracture surgeon appears to cause no significant increase in infections or delayed union/nonunions. In addition, early closure may decrease the requirement for subsequent debridements and soft-tissue procedures, thereby minimizing surgical morbidity, shortening hospital stays, and reducing costs. We feel that a randomized, prospective study of this aggressive approach to open fracture care is warranted.

Diaphyseal forearm fractures treated with and without bone graft.

BACKGROUND: The purpose of this study was to determine whether the acute bone grafting of diaphyseal forearm fractures decreases the incidence of nonunion and reduces the time to union. Although the traditional treatment of comminuted radius and/or ulnar shaft fractures involves bone graft, a recent report called into question this practice. PATIENTS: A database search was used to identify all acute diaphyseal forearm fractures presenting to an urban Level I trauma center between 1988 and 1996. All radius and/or ulnar shaft fractures, as well as all Monteggia and Galeazzi fracture-dislocations, in patients with closed physes were included. The charts and operative reports were available for 64 diaphyseal forearm fractures in 49 patients. Fifty-six fractures were followed for at least 1 year beyond clinical and radiographic union. The injuries were treated with open reduction and plate fixation by experienced orthopedic traumatologists. All noncomminuted fractures were treated without bone graft. For the comminuted fractures, the decision to use bone graft was left to the discretion of the operating surgeon. RESULTS: Overall, 55 of 56 fractures (98%) achieved union at a mean of 49 days (range, 19-123 days), with the only nonunion occurring in a patient with a closed, noncomminuted Galeazzi injury. Among the 20 noncomminuted fractures, all of which were treated without bone graft, 19 (95%) achieved union at a mean of 50 days (range, 19-102 days). Among the 36 comminuted fractures, all 25 treated without bone graft achieved fusion at an average of 50 days (range, 20-123 days) and all 11 treated with bone graft achieved union at an average of 45 days (range, 22-67 days). No statistically significant difference in the incidence of nonunion or time to union was noted between fractures that were treated with and without bone graft. CONCLUSION: Acute bone grafting of diaphyseal forearm fractures did not affect the union rate or the time to union.

Imaging of calcaneal fractures.

The radiologic evaluation of injuries to the calcaneus begins with plain x-rays. The addition of special views may be necessary as part of the preliminary evaluation to assist in the diagnosis or in further delineating the extent of the fracture. CT scanning is generally required for preoperative planning when there is extensive comminution and/or intra-articular involvement. MRI has a limited role in the treatment of calcaneus fractures.

Train injuries in children.

OBJECTIVE: To describe the pattern of injuries sustained in pediatric victims of train accidents. DESIGN: Retrospective review of patients identified in a search of two trauma registries for the years 1984-1994. SETTING: Two pediatric level one trauma centers in one metropolitan area. PATIENTS: Between 1984 and 1994, seventeen children were identified as treated for injuries sustained in train accidents. Children pronounced dead at the scene and those injured when a car was struck by a train were excluded. INTERVENTION: ATLS protocols were followed. All open musculoskeletal injuries were treated with multiple operative irrigation and debridement procedures and broad spectrum antibiotics. MAIN OUTCOME MEASUREMENTS: Variables included the following: age, sex, mechanism of injury, circumstances surrounding the injuries, all injuries sustained, operations performed during the acute hospitalization, subsequent operations, level of amputation(s), complications, and cost and length of hospitalization. RESULTS: Presenting injuries included eight patients with ten complete amputations and eight patients with ten near-complete amputations. The average number of operative procedures for the survivors during the initial hospitalization was 5.7 (range three to sixteen). Five patients (five extremities) required amputation revision to a more proximal level after the initial surgical intervention but prior to definitive wound closure. Secondary surgical procedures have been required in 50% of survivors to date. The financial cost of these injuries is substantial, with acute hospitalization costs averaging $61,000. CONCLUSION: Pediatric survivors of train-pedestrian accidents are likely to suffer isolated musculoskeletal injuries, the majority of which are amputations of the lower extremity. These injuries require multiple operative debridements and frequent revision to higher levels of amputation are expected. The percentage of these injuries in children at play around railroad tracks emphasizes the need for limitation of access to railroad areas and for prevention through public education.

Graft-versus-host disease in limb transplantation: digital image analysis of bone marrow and TGF-beta expression in situ using a novel 3-D microscope.

A subpopulation of parental to hybrid VBMT recipients developed characteristic clinical and histopathologic manifestations of GVHD. These changes are similar to those seen in human GVHD secondary to bone marrow transplantation. Human GVHD also manifests itself in an acute and chronic manner. Only a minority (30% to 40%) of animals developed lethal GVHD in our model. Those animals developing GVHD had a significantly (P < .0001) higher expression of TGF-beta in situ compared to the tolerant subpopulation. The differential expression of TGF-beta may represent an important mechanism of immune dysregulation associated with GVHD in CTA recipients.

Surgical management of soft tissue lesions associated with pelvic ring injury.

Mortality rates associated with pelvic ring injury combined with open wounds have decreased considerably during the past 2 decades. Consequently, increased survivability has heightened the demand for definitive stabilization techniques to address pelvic ring instability. Control of hemorrhage and avoidance of sepsis remain paramount concerns in the initial and later stages of management, respectively. Exclusion of occult and readily apparent perforations of the genital urinary and gastrointestinal tracts is essential when using a multidisciplinary approach. Recognition of open and closed degloving injury patterns and appropriate adherence to treatment guidelines will optimize outcome and avoid catastrophic complication.

Patterns of injury and disability caused by forklift trucks.

Over a 7-year period, 34 patients were treated at the Southern New Jersey Regional Trauma Center for forklift-related injuries, ranging from minor contusions to multiple organ-system trauma. Hospital and rehabilitation courses were prospectively evaluated, documenting long term impairment of function and disability. Patients injured by falling from forklifts generally had less severe injuries, requiring fewer surgical procedures, shorter hospital stays, and less overall disability, than patients who received crush-type (object-oriented) injuries. The more serious injuries were most frequently caused by a forklift striking or running over the patient. There were strong correlations between the Injury Severity Score assessed upon initial evaluation and subsequent length of hospitalization, degree of disability, and extent of functional impairment after recovery. These findings support the enforcement of existing safety precautions for the operation of forklift trucks.

Open fractures of the patella: long-term functional outcome.

Seventy-nine open patella fractures in 76 patients were treated between 1986 through 1994, with an 80% incidence of multiple injuries. All were treated with irrigation and debridement, open reduction, internal fixation, and reconstruction of the extensor mechanism. In no case was a primary patellectomy performed, even with severe comminution. There were three failures of initial fixation and one asymptomatic nonunion. Average range of motion for all groups was 112 degrees, at an average follow-up of 21 months. Secondary surgical procedures were performed in 65% of knees, the majority for symptomatic hardware. To determine long-term functional outcome, a modified Hospital for Special Surgery knee score was used. At an average of 36 months, good to excellent knee scores were observed in 17 of 22 patients. We conclude that all attempts for preservation of bone substance and precise reconstruction of the extensor should be attempted, reserving total patellectomy as a salvage procedure.

Open dislocation of the knee.

Traumatic open dislocation of the knee is an infrequent, severe injury associated with extensive ligamentous damage and a high incidence of vascular and neurologic involvement. Eighteen patients with 19 open knee dislocations were treated at the affiliated hospitals of the University of Pennsylvania and Louisiana State University Medical Center during an 18-year period. Final results included three above-knee amputations, one knee fusion, and one total knee arthroplasty. The 14 knees salvaged had only fair to poor function according to the Hospital for Special Surgery Knee Injury Score at an average follow-up of 36 months after the injury (average score = 29, range - 17 to 37). Nine patients (47%) had concomitant neurologic or vascular injury, and eight patients (42%) had wound healing difficulties. Five complete disruptions of the popliteal artery or posterior tibial artery underwent emergent revascularization, successful in three of the extremities, with the remaining two extremities requiring above-knee amputations. These massive injuries are often limb-threatening despite prompt surgical intervention and early antibiotic therapy. There is a very high incidence of infection and neurologic injury with a guarded prognosis for limb survival and satisfactory function.

Early exchange intramedullary nailing of distal femoral fractures with vascular injury initially stabilized with external fixation.

Fracture of the femur with accompanying arterial injury represents approximately 1% of all femoral fractures. Controversy exists regarding the choice of fixation and the sequence of fixation and vascular repair. We report on the treatment of six patients with seven distal femoral fractures and angiographically documented arterial injuries treated over a 20-month period. The treatment protocol consisted of angiography followed by provisional external fixation and early primary exchange to an intramedullary nail. Five of the seven fractures were open. Three fractures were caused by blunt trauma, and four were secondary to shotgun blasts. Average follow-up was 12 months (range, 6-25 months). All fractures healed with an average time to union of 25 weeks. There were no complications related to the vascular repair. One case of an acute deep infection resolved after debridement and placement of polymethylmethacrylate cement beads impregnated with antibiotics and a course of intravenous antibiotics. All patients returned to their previous levels of activity. Based on the results of our experience with a small group of patients, we feel that this treatment protocol will prove to be a safe and efficient method of management of these difficult injuries.

Initial experience with the treatment of supracondylar femoral fractures using the supracondylar intramedullary nail: a preliminary report.

Initial experience at a Level I Trauma Center with the use of a retrograde supracondylar intramedullary (IM) nail for the treatment of supracondylar and supracondylar-intercondylar intraarticular fractures of the distal femur is presented. Thirty-eight patients with 41 complex distal femur fractures were treated with this newly developed retrograde IM rod. These included 22 open fractures and 19 closed fractures. Four nonunions occurred, but all progressed to union after revision internal fixation and bone grafting. Two of five delayed unions required revision fixation. Two required screw renewal and dynamization. Thirty-five of 41 knees achieved at least 90 degrees of knee motion. There were no infections and no problems with wound healing. Four patients developed fatigue fractures of the rod. These mechanical failures occurred when 11- and 12-mm nails were used in conjunction with 6.4-mm interlocking screws. The rod system was therefore modified to include 12- and 13-mm diameter nails and smaller 5.0-mm interlocking screws. There have been no subsequent nail failures. We are cautiously optimistic that supracondylar IM rod fixation will contribute to the management of these difficult fractures. However, further clinical trials and additional biomechanical testing should be undertaken prior to widespread use of this device.

Three-dimensional computerized tomographic demonstration of bilateral atlantoaxial rotatory dislocation in an adult: report of a case and review of the literature.

A rare case of bilateral atlantoaxial rotatory dislocation (Fielding type V) in an adult is presented. The diagnosis was rapidly made by computed axial tomography. Prior reports of this entity have not clearly defined the pathoanatomy, which in our case was confirmed by three-dimensional tomographic reconstruction. We offer a clarification of the anatomic lesion and a discussion of this injury, which may make recognition and treatment of future cases easier.

False aneurysm of the medial inferior genicular artery after intramedullary nailing of the tibia.

Although rare, arterial false aneurysm about the knee has been a well-documented complication of many types of surgery. False aneurysms have been reported after such procedures as open meniscectomy, synovectomy, arthroscopy, total knee arthroplasty, and proximal tibial osteosynthesis. Arteries injured in these procedures have included the popliteal artery and the descending, medial superior, medial inferior, lateral superior, and lateral inferior genicular arteries. An extensive review of the literature showed no cases of false aneurysm after intramedullary nailing of the tibia.

Laparoscopic retrieval of a migrating intrapelvic pin: case report and review of the literature.

Migration of orthopedic implants is a well documented phenomenon. Prompt recognition and immediate retrieval may prevent significant and potentially fatal sequelae. The following report describes a unique case in which laparoscopic techniques were successfully used to recover a migrating intrapelvic pin.