The Radiographic Quality of Distal Radius Fracture Reduction Using Sedation Versus Hematoma Block.

INTRODUCTION: Distal radius fractures (DRFs) are treated in the emergency department (ED) with a closed reduction in order to decrease neurovascular and soft tissue injury and as a first definitive step in conservative treatment. The type of anesthesia used may affect the ability to reduce the fracture and remains controversial. OBJECTIVE: The purpose of this study was to compare the quality of radiographic reduction achieved in the ED of DRF reduced using sedation anesthesia to those reduced with hematoma block anesthesia. METHODS: A retrospective case-control study of 240 DRF reductions, 30 treated with sedation and 210 with a hematoma block, was performed. Complications and time spent in the ED were documented. Pre- and postreduction radiographs were reviewed for volar tilt, radial angulation, radial height, and ulnar variance. RESULTS: Both groups were similar in gender, background illnesses, concomitant injuries, surgeon experience, and fracture radiographic classification. Postreduction values of volar tilt were better in the sedation group (P = .03). Volar tilt and ulnar variance improved more in the sedation group (P = .001). The sedation group spent more time in the ED (P = .001). DISCUSSION: Sedation seemed to be more efficient than hematoma block in supporting closed reduction of distal radius fractures in the ED. However, this method requires specialized personnel and more time spent in the ED. CONCLUSION: We suggest using this method when the patient is planned to continue with conservative treatment.

HISTORIQUE: Les fractures distales du radius (FDR) sont traitées en salle d'urgence (SU) au moyen d'une réduction fermée afin de réduire les lésions neurovasculaires et celles des tissus mous. Cette technique représente la première étape décisive d'un traitement prudent. Le type d'anesthésie privilégié demeure controversé, car il peut influer sur la capacité de réduire la fracture. OBJECTIF: La présente étude visait à comparer la qualité des réductions radiographiques des FDR par sédation obtenues en SU à celles effectuées sous anesthésie locorégionale. MÉTHODOLOGIE: Les chercheurs ont effectué une étude rétrospective cas-témoins de 240 réductions de FDR, dont 30 traitées sous sédation et 210, sous anesthésie locorégionale. Ils ont consigné les complications et le temps passé en SU. Ils ont examiné les radiographies avant et après la réduction pour déterminer l'inclinaison palmaire, la déviation radiale, la hauteur radiale et la variance ulnaire. RÉSULTATS: Le sexe, les maladies antérieures, les lésions concomitantes, l'expérience du chirurgien et la classification radiographique des fractures étaient semblables dans les deux groupes. Les valeurs de l'inclinaison palmaire après la réduction étaient supérieures dans le groupe sous sédation (p=0,03). L'inclinaison palmaire et la variance ulnaire s'amélioraient également davantage dans ce groupe (p=0,001), qui passait toutefois plus de temps en SU (p=0,001). EXPOSÉ: La sédation semblait plus efficace que l'anesthésie locorégionale lors de la réduction fermée des fractures distales du radius en SU. Cependant, cette méthode exige la présence de personnel spécialisé et une période plus longue en SU. CONCLUSION: Les chercheurs suggèrent d'utiliser la sédation lorsqu'il est prévu que le patient poursuive un traitement prudent.

Multiplanar Deformities Correction Using Taylor Spatial Frame in Skeletally Immature Patients.

BACKGROUND: Taylor Spatial Frame (TSF) is a modern circular external fixator that, using a virtual hinge, is able to correct six axis deformities simultaneously. Despite the growing popularity of this method, few reports exist about its use in children and adolescents. To evaluate the effectiveness of TSF in correcting multiplanar deformities in patients with open physis, we reviewed the results of treatment in children who had at least two planes deformities of lower limbs. METHODS: Over a period of 8 years, we treated 51 patients, 40 boys, 11 girls, with a mean age of 12.4 years (range, 2-16 years). All patients had open physis at the time of the TSF application. All patients had at least two deformities (angular and/or rotational). Fifty-five osteotomies (11 femoral, 44 tibial) were performed. Patients were divided into four groups: 13 with post-traumatic malunions, 18 with tibia vara, six with rickets, and 14 with miscellaneous deformities. Correction goal was determined as correction of deformities to population-average parameters of the lower limbs in frontal and sagittal views and normal mechanical axis deviation. RESULTS: Correction goal was achieved in all except one patient; four patients had recurrence of deformities post-operatively and were re-operated. Most common complications were pin tract infection (20 patients), delayed union (2), regenerate translation (1), post-removal femoral fractures (2), knee subluxation (1), nonunion (1), and one patient developed chronic osteomyelitis secondary to deep pin tract infection. CONCLUSION: TSF allowed accurate correction of complex limb deformities in children and adolescents with relatively few serious complications. LEVEL OF EVIDENCE: Level IV. Case series.

Hyperbaric oxygen for stage I and II femoral head osteonecrosis.

Hyperbaric oxygen therapy is a suggested joint-preserving treatment for symptomatic early-stage osteonecrosis of the femoral head. Limited studies of this treatment have been published. The goal of this study was to evaluate the effectiveness of this treatment in a relatively large patient cohort. The authors reviewed the files of 68 patients with 78 symptomatic joints with Steinberg stage I and II osteonecrosis of the femoral head. All patients were treated with hyperbaric oxygen at the authors' medical health center. Pretreatment and immediate posttreatment magnetic resonance imaging (MRI) findings were compared. On follow-up, a telephone interview was conducted to determine the survival of the joint. Modified Harris Hip Score and Short Form 12 health survey (SF-12) questionnaires of the start of treatment and at follow-up were obtained and evaluated for statistically significant differences. Half of the joints were stage 1 and half were stage II. Seventy-four joints underwent both pre- and posttreatment MRI. Eighty-eight percent of joints showed improvement posttreatment. On follow-up at a mean of 11.1±5.1 years, 54 patients (58 joints) were located and answered the questionnaires. At the time of follow-up, 93% of the joints survived. Mean Harris Hip Score improved from 21 to 81 (P<.0001), the mean physical component of the SF-12 improved from 24 to 46 (P<.0001), and the mean mental component of the SF-12 improved from 54 to 59 (P<.0001). The authors concluded that hyperbaric oxygen treatment is effective in preserving the hip joint in stage I and II osteonecrosis of the femoral head.

Effect of seasonality, weather and holidays on the incidence of proximal hip fracture.

BACKGROUND: Proximal hip fractures in the elderly are common and place a heavy burden on health resources. Researching the timing of these fractures could contribute to diverting resources towards peaks in incidence and investing in prevention at certain times. OBJECTIVES: To examine the effect of seasonality, weather and Jewish holidays on hip fracture incidence in older adults. The study population comprised 2050 patients aged 65 years or more who sustained a proximal hip fracture. METHODS: The computerized files of the patients were reviewed for trends in incidence by season, precipitation, minimum and maximum temperatures, day of the week, and certain Jewish festivals. RESULTS: Hip fractures were more likely to occur in the winter than in the summer (P < 0.0001). Factors that significantly correlated with hip fracture were the maximum daily temperature (r = -0.746, P = 0.005) followed by the minimum daily temperature (r = -0.740, P = 0.006) and precipitation (r = 0.329, P = 0.02). There were fewer fractures on Saturdays (the Sabbath) as compared to other days of the week (P = 0.045). Researching the incidence on Jewish holidays, we found an elevated incidence on Passover (P < 0.0001) and a reduced incidence on the Day of Atonement (Yom Kippui) (P = 0.013). CONCLUSIONS: In older people there is an elevated incidence of proximal hip fractures during the winter and on the Jewish festivals. On weekends and on the Day of Atonement the incidence of proximal hip fractures was reduced.

Amputation of finger by horse bite with complete avulsion of both flexor tendons.

Amputation of fingers with tendon avulsion occurs through a traction injury, and most occur through a ring avulsion mechanism. Usually the flexor digitorum profundus is torn out with the amputated finger. Replantation usually is recommended only when the amputation is distal to the flexor digitorum superficialis insertion. Animal bites are relatively common, with a decreasing order of frequency of dogs, cats, and humans. Horse bites are relatively infrequent but are associated with crush injuries and tissue loss when they occur. This article describes a 23-year-old man with amputation of his middle finger at the level of the proximal phalanx after being bitten by a horse. The amputated stump was avulsed with the middle finger flexor digitorum profundus and flexor digitorum superficialis torn from the muscle-tendon junction from approximately the middle of the forearm. The patient had no other injuries, and he was able to move his other 4 fingers with only mild pain. As the amputated digit was not suitable for replantation, the wound was irrigated and debrided. The edges of the phalanx were trimmed, and the edges of the wound were sutured. Tetanus toxoid and rabies vaccine were administered, along with intravenous amoxicillin and clavulanic acid. The patient was discharged from the hospital 2 days later, with no sign of infection of the wound or compartment syndrome of the forearm. This case demonstrates the weakest point in the myotendinous junction and emphasizes the importance of a careful physical examination in patients with a traumatic amputation.

[Burns--risk factors and treatment].

Burn injuries are very frequent and afflict approximately 1% of the population yearly. They are a source of heavy medical burden to medical systems worldwide. In the US alone, about 2 million burns are treated by medical staff yearly, and about 75,000 burns are serious enough to require hospitalization. In the UK, a similar situation is depicted in the statistics--burns constitute 1% of the ER workload, and 0.014% of the hospitalization. Morbidity and mortality from burns is mainly dependent upon: total body surface area (TBSA) that is involved in the burn, the depth of the burn and it's anatomical location, the age of the subject, prior medical history and the severity of adjacent injuries (especially pulmonological injury). TBSA is calculated by age-adjusted tables. There are a number of ways to determine this parameter, the simplest of all is called "the rule of 1/9". Using this technique we divide the body into distinct areas, each equal to 1/9 of the TBSA. The treatment of burn injuries is considered one of the most difficult in the medical profession and some even compare it to the treatment of ICU patients. The primary treatment in burns always involves the removal of the patient from the source of the thermal injury, securing his airway (especially in patients suspected of inhalation injury) and an aggressive fluid resuscitation. Fluid resuscitation is mainly managed using the Parkland equation. The treatment of the burned skin is by one of two regimes--the conservative regime (frequent redressing of the burn site, hygiene and antimicrobial treatment) and the surgical regime (early intervention with debridement, skin implantations etc.). Several different studies have shown a decrease in the mortality rate of severe burn patients who have undergone an early surgical regime in comparison to conservative treatment.

The effect of Lactobacillus bacteria supplement on sepsis and its complications in patients with acute burns.

Sepsis as a result of bacterial translocation from the gastrointestinal tract (GIT) is a known associate of morbidity and mortality in patients with severe burns. This translocation is influenced by the GIT flora. Oral consumption of Lactobacillus bacteria was previously shown to reduce translocation. We conducted a retrospective cohort study on a series of 56 patients with burns admitted to Soroka University Medical Center in Beer-Sheva, Israel. Those 56 patients included 28 who were given lactobacillus supplements and 28 who were not. The parameters that were compared between the groups evaluated the level of sepsis and its complications. The parameters of morbidity during hospitalization were significantly higher in the treatment group; however, their mortality was lower. That difference in mortality between the groups was not significant as a whole (p=0.071), but it was significant in the subgroup analysis of 41-70% total body surface area burned. In that subgroup there were zero cases of death in the treatment group versus five cases in the control group (p=0.005). Our findings suggest that in acute burns, lactobacillus bacteria food additives may be clinically beneficial in patients with total burned body surface area of 41-70%.