Fracturas abiertas (II): tratamiento

El tratamiento de la gran variedad de lesiones óseas y de partes blandas que acompañan a una fractura abierta requiere criterio y experiencia. Parece que el enclavado intramedular no fresado bloqueado puede estabilizar de forma fiable y reproducible la mayor parte de fracturas de baja energía (I y II de Gustilo) y algunas seleccionadas de alta energía de la extremidad inferior (IIIa). Las fracturas abiertas graves requieren de un protocolo de reconstrucción paso por paso, que asocia la fijación externa como método de estabilización inicial. La diferenciación entre las necesidades de cada fractura individualizada es la clave del éxito. El tratamiento de la gran variedad de lesiones óseas y de partes blandas que acompañan a una fractura abierta requiere criterio y experiencia. Parece que el enclavado intramedular no fresado bloqueado puede estabilizar de forma fiable y reproducible la mayor parte de fracturas de baja energía (I y II de Gustilo) y algunas seleccionadas de alta energía de la extremidad inferior (IIIa). Las fracturas abiertas graves requieren de un protocolo de reconstrucción paso por paso, que asocia la fijación externa como método de estabilización inicial. La diferenciación entre las necesidades de cada fractura individualizada es la clave del éxito (AU)

Fracturas abiertas (I): evaluación inicial y clasificación

Las fracturas abiertas son debidas, en general, a una mayor violencia del traumatismo respecto a las fracturas cerradas y, por tanto, hacen prever un mayor número de complicaciones. Se produce un mayor grado de contusión de las partes blandas, como son los vasos, los nervios y, fundamentalmente, los músculos y la piel. Si a todo ello se añade la habitual conminución de los fragmentos, la contaminación bacteriana encontrará en las fracturas abiertas un espléndido marco para su desarrollo y ulterior aparición de la infección ósea. Las fracturas abiertas constituyen una urgencia absoluta, puesto que las probabilidades de infección aumentan con el paso del tiempo. La base fundamental del tratamiento de las fracturas abiertas es conseguir la consolidación de la fractura y prevenir la infección ósea postraumática. Para ello es necesario actuar correctamente sobre la piel y las partes blandas, así como sobre la fractura mediante una correcta estabilización, indispensable para obtener la consolidación de la fractura, la cicatrización de las partes blandas y la prevención de la infección (AU)

Femoral head necrosis after intertrochanteric fracture: a case report after synthesis with Ender nails.

A case of femoral head necrosis in a patient who suffered an intertrochanteric fracture, treated with Ender nails 1 year before, is presented. The rarity, and possible mechanisms (reduction and type of osteosinthesis) of necrosis are discussed.

Treatment of Galeazzi fracture-dislocations.

Among 33 patients with a Galeazzi-type fracture-dislocation of the forearm, there were two children and 26 adults with a classic Galeazzi injury, and five patients with a Galeazzi-equivalent lesion. The worst results were obtained in type-I lesions. Closed reduction was primarily successful in children. The results of surgical treatment were much better in adults. It is advisable to treat this complex injury by anatomic reduction and internal fixation of the radial shaft fracture. Immobilization in a fully supinated position is recommended to reduce the dislocation of the distal radioulnar joint. Additional temporary radioulnar fixation with Kirschner wires is also necessary in cases of severe derangement of the distal radioulnar joint.

Osteochondritis dissecans of the patella. 12 cases followed for 4 years.

Osteochondritis dissecans of the patella in 9 patients (6 men, 3 women; mean age 19 years) was located in the median ridge and paramedial areas and was bilateral in 3 patients. All patients were initially treated conservatively with complete relief of symptoms in 5. In 7 patients fragments were excised and the crater was curetted and drilled. At follow-up after 4 (2-8) years, the patients had no restriction of activities and they had no pain.

[The therapeutic posture in desmoid tumor]. / Actitud terapéutica ante el tumor desmoide.

BACKGROUND: The desmoid tumor is a histologically benign neoplasm originating in muscular-aponeurotic structures and possesses a high tendency of local recurrence. The aggressive nature of the tumor obliges radical surgery to be performed principally in extra-abdominal tumors. METHODS: Twelve patients were treated from 1983 to 1993. The treatments performed prior to and after histologic diagnosis, the time of evolution when radical treatment was carried out upon diagnosis and the evolution after treatment were evaluated. RESULTS: Of the patients with desmoid tumor 8 were males with a mean age of 29.9 +/- 12.5 years. In eleven cases the presentation was as a tumor and was of pain in only one case. All the patients were surgically treated with a total of 27 interventions being carried out. Three patients also received pharmacologic treatment with tamoxifen, in 2 cases associated to sulindac. In two radiotherapy was used but not as a first line treatment. Following a mean follow up of 38 +/- 17 months no mortality has been registered but 5 patients are not disease free. CONCLUSIONS: The therapeutic attitude to the desmoid tumor should be radical surgery in both the primary tumor and the recurrences with medical treatment being performed in specific situations.

[Nickel, chromium and cobalt release from a metal prosthesis in metal-sensitive patients]. / Liberación de níquel, cromo y cobalto de prótesis metálicas en pacientes sensibles a metales.

Six rejected stainless steel hip prostheses that had been removed from 15 metal sensitive patient were immersed in different solutions in various containers and maintained at 37 degrees C in complete darkness. Two months later by means of atomic absorption spectrophotometric studies we were able to determine the amount of nickel, chrome and cobalt released in a saline solution. When the chromium oxide passivation coat of the metal prostheses is damaged by orthopaedic surgical implantation procedures the prostheses may rust, releasing metallic ions.

[Nerve graft predegenerated in situ, and fresh nerve graft. Comparative study in the rabbit]. / Greffe nerveuse prédégénérée "in situ", et greffe nerveuse fraîche. Etude comparative chez le lapin.

Experimental studies have been made in rabbits in which an operative gap in the nerve was bridged either with a fresh nerve graft taken from the opposite side or with a degenerate graft, the nerve on the opposite side having been divided 15 days earlier. Technical details of the method are described. An electromyographic study demonstrated better results with the predegenerate graft and histological examination showed a better maturation of the axons.

Internal fixation of fractures of the proximal end of the radius in adults.

Eight cases of internal fixation for fractures of the proximal end of the radius in adults are discussed. The reasons for this procedure, after considering the patient's age and activity and the type of fracture, was to avoid the sequelae of resection of the radial head. By following an appropriate technique, and provided that there are no compications, the results obtained have been excellent.