Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management.

OBJECTIVE: To report on all complications experienced by patients with displaced intra-articular calcaneal fractures (DIACFs) following nonoperative management or open reduction internal fixation (ORIF). DESIGN: Prospective, randomized, multicenter study. SETTING: Four level I trauma centers. PATIENTS: The patient population consisted of consecutive patients, age 17 to 65 at the time of injury, presenting to 1 of the centers with DIACFs between April 1991 and December 1998. INTERVENTIONS: Patients were randomized to the nonoperative treatment group or to operative reduction using a lateral approach to the calcaneus. MAIN OUTCOME MEASUREMENTS: Follow-up for patients was at 2 weeks, 6 weeks, 3 months, 12 months, 24 months, and once greater than 24 months following injury. At each follow-up interval, patients were assessed for the development of major and minor complications. After a minimum of 2-year follow-up, patients were asked to fill out a validated visual analogue scale questionnaire (VAS) and a general health review (SF-36). RESULTS: There were 226 DIACFs (206 patients) in the ORIF group with 57 of 226 (25%) fractures (57 of 206 patients [28%]) having at least 1 major complication. Of 233 fractures (218 patients) nonoperatively managed, 42 (18%) (42 of 218 patients [19%]) developed at least 1 major complication (indirectly resulting in surgery). CONCLUSION: Complications occur regardless of the management strategy chosen for DIACFs and despite management by experienced surgeons. Complications are a cause of significant morbidity for patients. Outcome scores in this study tend to support ORIF for calcaneal fractures. However, ORIF patients are more likely to develop complications. Certain patient populations (WCB and Sanders type IV) developed a high incidence of complications regardless of the management strategy chosen.

Intramedullary Steinmann pin fixation of forearm fractures in children. Long-term results.

The current study is a retrospective clinical and radiographic review of all children treated with intramedullary Steinmann pins for fixation of diaphyseal forearm fractures at one institution. Thirty patients were reviewed. Twenty-five patients had fractures of both bones, three had Monteggia fracture-dislocations, and two had isolated radial fractures. Eight fractures were open. The average age of the patients at the time of surgery was 9 years 3 months (range, 4 years 1 month-14 years 3 months). Time to union averaged 6 weeks but a slightly longer healing time was seen in patients older than 10 years of age. Subjective, objective, and radiographic evaluation at 3 years 6 months average followup revealed no significant side to side differences. There were six complications (two pin site infections, two cases of fracture displacement after pin removal, one extensor pollicus longus tendon rupture requiring repair, and one refracture), none of which affected outcome at followup. When combined with an open reduction, one intramedullary Steinmann pin provides adequate stability in most diaphyseal forearm fractures in children with excellent results and few complications.

Flexible intramedullary nail fixation of pediatric femoral fractures.

The management of pediatric femoral shaft fractures gradually has evolved toward a more operative approach in the past decade. This is because of a desire for more rapid recovery and reintegration of the patients, and a recognition that prolonged immobilization can have negative effects even in children. Economic pressures also favor a treatment that does not require as prolonged a hospitalization as that required with the traditional traction method. External fixation, compression plating, and intramedullary nailing all have been advocated. A retrospective review of the experience with antegrade flexible intramedullary nailing in 25 children was performed. No nonunions or significant malunions were seen. Followup evaluation of limb lengths and proximal femoral morphology showed minor variations of articulotrochanteric distance and neck shaft angle, none of which were clinically significant. Likewise, minor limb length discrepancies were measured (range, -11- +14 mm) with no consistent pattern of overgrowth noted. There was no evidence of a complete trochanteric growth arrest on radiographic followup. Flexible intramedullary nailing seems to be a safe and effective method for the treatment of femoral shaft fractures in the child between 6 and 12 years of age.

Evaluation of the role of comparison radiographs in the diagnosis of traumatic elbow injuries.

This study attempted to determine whether comparison radiographic views of the uninjured elbow result in increased diagnostic accuracy. Physicians (one junior and one senior orthopaedic resident and an orthopaedic surgeon) were provided with a short clinical summary and asked to interpret radiographs of the injured elbow (IE) or both the injured and uninjured elbow (UE) in a randomized fashion from 25 children with elbow injuries. The overall percentage of correct diagnoses (one vs. two elbow radiographs) were as follows: orthopaedic surgeon, 80 versus 96%; for junior resident, 80 versus 84%; and for senior resident, 84 versus 88% (p > 0.05). Kappa scores for interobserver variability and intrarater agreement were in the high range (0.756 to 0.904, kappa = 0.08). Clinically relevant diagnoses were missed by trainees (not the orthopaedic surgeon) whether radiographs of IE or both IE and UE were interpreted. Incorrect radiograph interpretations were due to false positives in 39 of 40 cases. Comparison radiographs of the UE were not useful in improving diagnostic accuracy in elbow trauma. However, although they may be necessary in some instances, routine radiographic examination of the UE is not warranted.

Intramedullary nailing of pediatric femoral fractures.

This retrospective study reviews our results with intramedullary nail fixation of 37 fractures of the femur in 35 skeletally immature patients. Five of these fractures were open. Twenty-two patients (average age 12 + 9 years) were treated with reamed intramedullary nails. Fifteen patients (average age 9 + 6 years) were treated with nonreamed nails. All fractures united in 6-12 weeks. There were no infections, delayed or nonunions, nor were there any incidences of avascular necrosis. There were very few significant complications. One patient required excision of heterotopic bone to restore hip motion. When surgical treatment of pediatric femur fractures is indicated, we prefer intramedullary nail fixation (either reamed or nonreamed) depending on age, fracture pattern (level, degree of comminution), and size of femoral canal. Experience and careful surgical judgment are required to appropriately individualize treatment for these patients.

Long-term follow-up of anterior tibial eminence fractures.

Most children who have sustained a tibial eminence fracture have objective evidence of anterior cruciate ligament (ACL) laxity at long-term follow-up, but few have subjective complaints. Clinical signs of anterior instability were noted in 64% of patients (32 of 50) examined at an average follow-up of 4 years. Objective evidence of laxity determined with a KT-1000 arthrometer was noted in 74% of patients (37 of 50). Five patients (10%) complained of pain, but no patient complained of instability at follow-up. Assessment of long-term stability showed that the method of management (open vs. closed methods) had no bearing on eventual outcome.

Use of comparison radiographs in the diagnosis of traumatic injuries of the elbow.

STUDY OBJECTIVE: To determine whether comparison radiographic views of the uninjured elbow result in increased diagnostic accuracy in elbow trauma. DESIGN: Physicians were provided with a short clinical summary and asked to interpret radiographs of the injured elbow or of both the injured and the uninjured elbow in a randomized fashion. SETTING: The radiology department in a university hospital. METHODS: Fifty sets of radiographs from 25 children with elbow injuries were reviewed by two residents, two emergency physicians, and one pediatric radiologist using a standard classification of injuries. For each child, there were two sets of radiographs: one of the injured elbow and one of both the injured and the uninjured elbow. Descriptive statistics were used to report the results. kappa statistics were used to determine interobserver and intraobserver agreement. Missed diagnoses were divided into those that were clinically relevant and those that were not. RESULTS: The overall percentage of correct diagnoses (one versus two elbow radiographs) were as follows: residents, 69% versus 70%; emergency physicians, 62% versus 67%; and pediatric radiologist, 74% versus 72% (P greater than .05). kappa scores for interobserver variability and intrarater agreement were in the moderate range (.383 to .805; kappa, .08). Clinically relevant diagnoses were missed by trainees and emergency physicians regardless of whether radiographs of just the injured elbow or both the injured and the uninjured elbow were interpreted. Incorrect radiograph interpretations were due to false-positives in 17 of 23 cases. CONCLUSION: Comparison radiographs of the uninjured elbow did not improve diagnostic accuracy in elbow trauma in the pediatric emergency department.

Control of interfragmentary micromotion in Ilizarov distractional osteogenesis.

Growth of the regenerate is affected by various factors during the course of Ilizarov distractional osteogenesis. One of the chief biomechanical factors that influences the quality and rate of bone formation is fixator stiffness. A four-ring Ilizarov apparatus was configured around a synthetic tibia. In a series of trials involving a uniform axial load, different transfixing wire tensions, and the separation of paired proximal and distal rings, fragment displacement was measured. Preliminary results suggest that the effect produced by the distraction of ring pairs on interfragmentary micromotion is as significant as pretensioning of the wires.

Bilateral lower extremity compartment syndromes secondary to intraosseous fluid resuscitation.

Intraosseous infusions are reserved for use in life-threatening hypovolemic or cardiogenic shock when intravenous (i.v.) access cannot be readily established. Although minor fluid extravasation is a common problem with this technique, a fully established compartment syndrome has never been reported. We describe a child with severe compartment syndromes of both lower extremities complicating the use of intraosseous fluid resuscitation.

Biomechanical analysis of pedicle screw instrumentation systems in a corpectomy model.

Five different spinal implants, all using pedicle screw attachment to vertebrae, were examined in a one above/one below corpectomy model, to determine 1) the relative stiffness of each construct, 2) the stresses generated in the implant during loading, and 3) the relative fatigue susceptibility of each implant. Results indicated that the relative axial and torsional stiffnesses were similar for all the implants tested (DKS/Zielke, VSP/Steffee, AO Fixator Interne, Luque plate, AO Notched plate). Hence, each of the devices impart approximately the same stability to the spine in this highly unstable model. Stresses measured at the root of the pedicle screws were found to exceed the endurance limit of stainless steel in those systems in which the pedicle screws were attached rigidly to the plates (VSP/Steffee, AO Fixator Interne). Good agreement was found between the measured stresses and stresses derived from static calculations. Comparisons between the stresses from each implant gave a relative measure of fatigue susceptibility that was validated by in vitro cyclic testing. Implants with stresses exceeding the endurance limit failed during the cyclic test.

One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening.

We reviewed the results of primary operative treatment in twenty-five patients (thirty-three hips) who were two years or older and had congenital dislocation of the hip. None of the patients had had previous treatment for the dislocation. Preliminary traction was not used in any patient. Femoral shortening and, in twenty-one hips, pelvic osteotomy were performed at the time of open reduction. At the most recent follow-up (average, three years and seven months), according to the radiographic classification system of Severin, there were seven excellent, seventeen good, and eight fair results; one hip had a poor result. Avascular necrosis developed in three of the thirty-three hips. At follow-up, these hips had a radiographic result of excellent, good, and fair, respectively. Twenty-one patients (twenty-eight hips) were reviewed with respect to range of motion and recovery from limb-length discrepancy. According to the rating system of Ferguson and Howorth, there were seventeen excellent, seven good, and three fair results; one hip had a poor result. It was concluded that children who are two years or older and who have a congenital dislocation of the hip can safely be treated with an extensive one-stage operation consisting of open reduction combined with femoral shortening and, often, pelvic osteotomy, without increasing the risk of avascular necrosis. The limb-length discrepancy that is produced by the shortening does not appear to cause a clinical problem.

Treatment of failures after plating of tibial fractures.

Eighteen patients with tibial fractures treated by plating that had failed were treated by intramedullary nailing. Nine patients had a broken plate or screw that had pulled out. In seven, the plate and screws were intact but no healing was evident, and in two patients the plate was intact but one or more screws were broken. The plate and screws were removed from all patients and immediate limited open intramedullary nailing was done with a Küntscher nail after the bone was reamed. In one patient the method failed, while in fifteen patients the fracture united and in the two remaining patients who could not be contacted union was thought to be in process when they were last seen, five and ten months postoperatively. Two bone grafts were used in one patient. Six fibular osteotomies were performed in conjunction with the intramedullary nailing.

A comparative analysis of operative versus nonoperative treatment of grade III acromioclavicular separations.

Nonoperative treatment (accepting the deformity with early range of motion and strengthening exercises) was compared with surgical treatment by Bosworth claviculocoracoid screw fixation of complete acromioclavicular dislocations. Nonoperative treatment provided an equal if not superior result, with an earlier return to activities, sports, and work. Neither the "bump" nor the scar was a significant cosmetic complaint. Range of motion and strength were equal, despite the treatment. Both groups were significantly weak in shoulder external rotator muscle power.

The use of the medial head of the gastrocnemius muscle in the posterior cruciate-deficient knee. Indications--technique--results.

This review retrospectively analyzes a group of patients with chronic posterior cruciate insufficiency who were treated surgically with transfer of the medial head of the gastrocnemius muscle. Our indications, technique, and the results of this surgery are presented. Twenty-one patients (21 knees) over the last 31/2 years, from January 1977 to June 1980, were treated by this procedure. Eighteen patients were followed up for more than 8 months after surgery and are included in the review. Subjectively, pain, swelling, reduction activity, and functional instability were assessed and graded from 0+ to 3+. Postoperative examination showed improvement of these parameters in most patients. Objectively, assessment of effusion, patellofemoral joint symptoms, stability, and recurvatum were tabulated and compared to preoperative information. Of greatest significance was improvement of the patient's overall functional classification in most cases. The posterior sag or drawer sign and patellofemoral complaints were not altered by the operation. Gait analysis and isokinetic testing were performed as part of the followup on 50% of the patients. We advocate this as a safe, effective reconstructive procedure for the posterior cruciate deficient knee with significant advantages over alternative techniques.

Selective attention and laterally in good and poor readers.

Good and poor readers recalled lists of three pairs of competing digits presented either Dichotically (separated by ear) or Spectral-Monotically (separated by voice frequency) and at different rates of presentation. Poor readers showed a reduced ability to attenuate unattended channels and, unlike good readers, showed poorest performance at the fast rate. These results suggest a specific attentional deficit, not merely representative of the poor readers' general tendency to do poorly on difficult language related tasks.