Open reduction internal fixation after displacement of a previously nondisplaced acromial fracture in a multiply injured patient: case report and review of literature.

SUMMARY: A twenty-eight-year-old multiple trauma patient had a nondisplaced acromion fracture that was not detected until after it had displaced. Open reduction internal fixation was performed without complication and the patient achieved excellent shoulder abduction strength. Nondisplaced acromion fractures may displace if not protected. Open reduction internal fixation of displaced acromion fractures should be considered if deltoid muscle strength is important to the patient.

Late arthroscopic debridement of metal fragments and synovectomy after penetrating knee joint injury by low-velocity missile: a report of two cases.

Retained metal debris from intraarticular missile injury to the knee may produce mechanical symptoms and synovitis. Arthroscopic debridement and thorough synovectomy can relieve symptoms and allow early return of function.

Supracondylar humerus fractures in children. Comparison of operative treatment methods.

A retrospective analysis was performed of 87 children treated operatively for supracondylar humerus fractures by 18 different surgeons during a 6-year period. No patient suffered from compartment syndrome or Volkmann's ischemic contracture. Early postoperative fracture displacement occurred in four (7%) of 60 patients with Type III fractures, and in one (4%) of 23 patients with Type II fractures. Displacement occurred in one (2%) of 52 Type III fractures stabilized with crossed medial and lateral Kirschner wires, whereas displacement occurred in two (28%) of seven Type III fractures stabilized with lateral wires only. Thirty-four patients could be located for long-term followup; complete examination of both upper extremities was performed on these 34 patients at an average of 33 months postoperatively. The long-term results were excellent in 19 (56%), good in seven (21%), fair in one (3%), and poor in seven (21%) patients. Five additional patients were not available for followup at the time of the current study, but had followup of at least 6 months available. Of the 39 patients with followup of at least 6 months, five patients' fractures (13%) healed with coronal plane malalignment greater than 10 degrees which resulted in gunstock deformity. There was no statistically significant relationship between treatment method and gunstock deformity. However, none of the patients with gunstock deformity had compromised activity because of the deformity, and all had full elbow extension and at least 130 degrees elbow flexion.

Musculoskeletal trauma in tobacco farming.

The incidence of musculoskeletal injury sustained during tobacco farming has been poorly documented. Using the trauma registry for all farm-related injuries occurring during a 16-month period, hospital charts, radiographs, and clinic charts were reviewed to identify those patients sustaining tobacco farming-related injury. Twenty-three of 24 persons who sustained a farm-related injury during the study period were injured while farming tobacco. Seventeen (74%) were injured in falls from vented tobacco-drying barns, and 18 (75%) sustained skeletal injury. Extreme heat, humidity, and poor barn design and maintenance contribute to the incidence of falling. These injuries, largely underreported, may be substantially reduced by improvements in barn design and construction.

Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft fractures: a randomized prospective study.

OBJECTIVE: To compare anterior and deep posterior compartment pressures during reamed and unreamed intramedullary nailing of displaced, closed tibial shaft fractures. DESIGN: Randomized prospective study. SETTING: University Hospital/Level I trauma center. PATIENTS: Forty-eight adults with forty-nine fractures treated with intramedullary nailing within three days of injury. INTERVENTION: After intraoperative placement of compartment pressure monitors, the tibia fractures were treated by either unreamed intramedullary nailing or reamed intramedullary nailing. A fracture table and skeletal traction were not used in any of these procedures. MAIN OUTCOME MEASUREMENTS: Compartment pressures and deltaP ([diastolic blood pressure] - [compartment pressure]) were measured immediately preoperatively, intraoperatively, and for twenty-four hours postoperatively. RESULTS: Compartment syndrome did not occur in any patient. Peak average pressures were obtained during reaming in the reamed group (30.0 millimeters of mercury anterior compartment, 34.7 millimeters of mercury deep posterior compartment) and during nail insertion in the unreamed group (33.9 millimeters of mercury anterior compartment, 35.2 millimeters of mercury deep posterior compartment). The average pressures quickly returned to less than thirty millimeters of mercury and remained there for the duration of the study. The deep posterior compartment pressures were lower in the reamed group than in the unreamed group at ten, twelve, fourteen, sixteen, eighteen, twenty, twenty-two, and twenty-four hours postoperatively (p < 0.05 at each of these times. A statistically significant difference between anterior compartment pressures could not be shown with the numbers available. The deltaP values were greater than thirty millimeters of mercury at all times after nail insertion in both the reamed and unreamed groups. CONCLUSION: These data support acute (within three days of injury) reamed intramedullary nailing of closed, displaced tibial shaft fractures without the use of a fracture table.

A mechanical comparison of subtrochanteric femur fracture fixation.

OBJECTIVE: To determine whether the mechanical properties of first-generation interlocking femoral nails are different from those of second-generation interlocking femoral nails in a subtrochanteric femur fracture model. DESIGN: Randomized laboratory investigation using a synthetic subtrochanteric femur fracture model. SETTING: Simulated stable and unstable fractures were created at three levels in the subtrochanteric region of synthetic femora. Instrumented specimens were tested elastically in a biomaterials testing system. INTERVENTION: Synthetic femora were instrumented with either a statically locked first-generation femoral nail or a statically locked second-generation femoral nail. MAIN OUTCOME MEASUREMENTS: Elastic stiffness for both the stable and unstable fracture groups was measured in both compression and torsion. Unstable fracture specimens were tested to failure in compression, and load to failure was measured. RESULTS: Throughout the subtrochanteric region, second-generation femoral nail constructs were consistently stiffer in compression and torsion than were statically locked first-generation femoral nail constructs. In general, second-generation constructs also withstood larger loads to failure in the unstable fracture model. CONCLUSIONS: Second-generation nails provided significantly enhanced mechanical stiffness compared with first-generation femoral nails when used to treat both stable and unstable subtrochanteric femur fractures. Although these results were obtained by using a well-controlled, mechanically consistent model, clinical validation of an increased incidence of fracture unions or of decreased time to union is required before we can recommend that second-generation nails be used routinely to treat subtrochantenic femur fractures.

The strength of iliosacral lag screws and transiliac bars in the fixation of vertically unstable pelvic injuries with sacral fractures.

This study compares the relative strengths of iliosacral lag screws and transiliac bars in the fixation of vertically unstable pelvic injuries with sacral fractures. A vertical sacral fracture was artificially induced by vertical loading in eight pelvises from cadavers, which were then fixed with two 6.5 mm iliosacral lag screws or two 6.4 mm transiliac bars. The pelvises were then loaded again to failure. The mean strength of iliosacral lag screw fixation was 819 newtons and for transiliac bars it was 1066 newtons, but the study was too small for the difference to be judged as statistically significant. Various advantages and disadvantages of each method of fixation are discussed.

Unrecognized foreign body in the hip joint.

A 40-year-old woman involved in a motor vehicle accident sustained a left acetabular fracture and a dislocated left hip with a large ipsilateral traumatic hip wound. Multiple plain radiographic films of the pelvis and a pelvic computed tomographic scan were obtained. None of these images showed a 25 x 20 x 12-mm piece of the gearshift that was found in the hip joint at the time of the surgery. Hence, we present this case highlighting an unusual phenomenon in which a large foreign body was not recognized on preoperative radiographic studies.

Tibiotalar contact area. Contribution of posterior malleolus and deltoid ligament.

Sixteen fresh ankle specimens were tested under physiologic loads to evaluate the effect on the tibiotalar contact area of increasing-size posterior malleolar fracture fragments and disruption of the deltoid ligament. The tibiotalar joint was maintained in a neutral position, and contact areas were recorded on pressure sensitive film. Posterior malleolar fracture fragments of 25%, 33%, and 50% as visualized on lateral radiographs were created. The deltoid ligament was sectioned after the final fracture fragment was made. There was a corresponding decrease of 4%, 13%, and 22% in tibiotalar contact area with the increasingly larger fracture fragments. The final disruption of the deltoid ligament did not alter the contact area. Statistical analyses using Student's t-test showed a statistically significant decrease in tibiotalar contact area in the samples with a fracture fragment of 33% and 50% involvement of the joint as compared with the control samples. Transection of the deltoid ligament produced no statistically significant further change in contact area. Displaced posterior malleolus fractures produce a significant decrease in contact area with 33% or greater involvement of the joint, which may predispose the tibiotalar joint to degenerative changes that should be lessened by anatomic reduction and internal fixation. Disruption of the deltoid ligament does not appear to alter contact area further, supporting the concept of repair as optional.

Lateral extension of the ilioinguinal incision in the operative treatment of acetabulum fractures.

The choice of which decision to use for open reduction and internal fixation of complex acetabulum fractures depends on several variables. We report on 26 patients in whom a lateral extension of the ilioinguinal incision was used to achieve fracture reduction and stabilization. The lateral extension allowed visualization of the lateral ilium, in some cases passage of cerclage wires around the anterior and posterior columns, and in some cases placement of lateral to medial lag screws above the dome of the acetabulum. Reduction with a step of 1 mm or less and a gap of 3 mm or less with joint congruence was achieved in 21 patients (81 per cent). No patients had clinically significant heterotopic ossification. One patient had a transient postoperative femoral neuropathy, one a superficial infection, and one a deep infection. We recommend this lateral extension as an option during surgery of complex acetabular fractures through the ilioinguinal incision.