Early and late results of controlled ventilation in flail chest.

From 1967 through 1974, a consecutive series of 35 patients with flail chest were treated with intermittent positive-pressure breathing (IPPB). The controlled ventilation contributed to stabilization of the thoracic cage in a favorable position for healing of the fractures. Surgical stabilization of the chest was not attempted in any of the cases. During treatment with IPPB, one patient died from profuse bleeding due to a generalized coagulation disorder, but the remaining 34 were discharged in a satisfactory respiratory condition. A late follow-up study of the pulmonary function one to eight years after the trauma included x-ray films of the trachea and lungs, kymographic studies of the diaphragm, spirometric and radiospirometric testing, and arterial blood gas levels. Eighteen patients were examined. Spirometric testing revealed astonishingly little impairment of the total pulmonary function. The radiospirometric studies with 133xenon showed a significant reduction of the regional perfusion only in five patients (2 to 4.5 pulmonary segments). Kymographic study of the diaphragm gave no further information and was less selective compared with the other tests of pulmonary function. Owing to the encouraging early and late results in this study, early treatment with IPPB is considered to be the method of choice in flail chest with paradoxic respiratory movements.

Fractures of the scaphoid.

Fracture of the scaphoid is the most common injury of the carpus. Inadequate treatment frequently leads to non-union, which causes pain and serious disability. In the present study 134 scaphoid fractures treated during the period 1961-70 are reviewed. In fresh fractures less than 4 weeks old, bony union occurred in 95% with proper conservative treatment. The vexed question of whether a high or low circular cast should be used may not really be so important. In the present study, both methods of external splintage have given favourable results. It is indisputable, however, that other factors, such as the age of the fracture, its type and location are of great importance for the final result. It was also found that fracture dislocation greater than 1 mm regularly led to pseudarthrosis. Operative treatment is suggested in these cases, and the Matti-Russe technique has proved to be an excellent method for treatment of pseudarthrosis of the scaphoid. The study further confirmed that fractures of the scaphoid in children are more common than is usually supposed. They were all located in the distal two-thirds of the bone and it is suggested that this pattern of distribution is typical of childhood.

Metacarpophalangeal joint implants. I. Roentgenographic study on the silastic finger joint implant, swanson design.

A roentgenographic study was carried out on 104 Silastic Finger Joint Implants, Swanson design. Sixty-two of the implants were examined in the anterio-posterior-projection (AP) from 4 months to 5 1/2 years postoperatively, a total of 116 examinations. Forty-two implants were examined in the AP-projection and in the lateral projection by tomography in maximum active extension and flexion from 9 days to 42 months postoperatively, a total of 110 examinations. Stem fractures were found in 11/104 implants: two of these preceded by a laceration of the implant surface visualized by tomography. Fragmentation of the midsection was found in 14/104 implants. Cortical erosion was seen radially in the phalanx and the metacarpal bone in some joints showing ulnar deviation, predominantly MCP joints II and III. On the tomograms a cortical erosion dorsally in the metacarpal bone could be demonstrated. Particularly around the distal stem was found an intramedullary bone lamella, varying in distance from the stem as well as in density and regularity. Bone resorption was found at the site where the midsection bore on the metacarpal bone and the proximal phalanx, resulting in a migration of the implant in a proximal and/or distal direction. The migration of the implant was evaluated on the tomograms with maximum active extension and classified into 4 Grades. Concomitant with the migration in the proximal direction a bony spur developed volarly at the resected end of the metacarpal bone, also seen in the AP-projection. The degree of maximum joint flexion was measured on the tomograms by drawing a line along the dorsal contour of each bone. In some cases flexion was found to decrease as a consequence of implant migration in the distal direction or the development of a bony spur. In several cases the range of flexion was maintained by gliding of the stems, particularly the distal one.

Respiratory function in esophageal hiatus hernia. I. Spirometry, gas distribution, and arterial blood gases.

As a part of a preoperative investigation, spirometry and blood gas tensions were studied in 64 subjects with X-ray-verified hiatus hernia (34 sliding, 22 mixed, and 8 of paraesophageal variety). According to the transverse diameter of the hernia. They were divided into 3 groups, small (2-5.9 cm), medium (6-9.9 cm), and large (10-17 cm) hernias. No correlation between the size of the hernia, reflux incidence, and spirometric findings could be demonstrated. A significant reduction of the arterial oxygen tension was found in small hernias and in vital capacity and maximal voluntary ventilation (MVV) in medium-sized hernias. Significant reduction in MVV was noted in the large hernia group. A common spirometric finding in all groups was a significant increase in residual volume and wash-out volume. The incidence of restrictive or obstructive pulmonary impairment was high in large (39%) and small (32%) hernias and relatively low in medium-sized hernias (8%). Roentgenological fibrosis was not found in any of the patients, while 4 showed emphysematous changes.