Testicular Dislocation After Pelvic Ring Injury: A Report of 2 Cases.

CASES: We present 2 cases of traumatic testicular dislocation associated with a pelvic ring injury after a motorcycle collision. Case 1 describes bilateral testicular dislocation discovered intraoperatively. Urology was consulted, and the testicles were manually reduced under general anesthesia. Case 2 describes unilateral testicular dislocation discovered at the 1-month follow-up after pelvic ring fixation. Concern for infarction prompted urology to take the patient for surgical reduction. Both cases resolved uneventfully without genitourinary complaints at the follow-up. CONCLUSIONS: Testicular dislocation is rare but should be considered in the setting of pelvic injury due to a motorcycle collision. Detection warrants urgent urologic consultation.

Migration of a K-wire from the distal radius to the heart.

K-wires and Steinmann pins are used to provide internal fixation for fractures or osteotomies. In some instances, removal of the implant is planned and the implant is left long to facilitate its removal. In other instances, implant removal is not planned and the implant is cut off at the level of the bone. Migration of these implants to solid organs or body cavities has been reported. Extravascular migration may occur along tissue planes assisted by muscle motion. Large vessel penetration can occur and has been reported with subsequent migration of the implant to the heart. This case report documents the loosening of a K-wire used in the distal radius to supplement the fixation of a complex intra-articular fracture, migration of the implant along tissue planes, penetration into a peripheral vein, and continued migration of the implant to the heart. There are multiple reports documenting wandering bullets, venous catheter tips, and invasive monitoring devices in the extremities. This is only the second case report that the authors are aware of that confirms migration of an implant from the distal extremity to the heart.

The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review.

OBJECTIVE: To determine the union rate of forearm fractures where acute bone grafting was recommended but not performed. DESIGN: Retrospective review. SETTING: Regional level one trauma center. PATIENTS: The criteria for inclusion in the study were patients with closed growth plates and a diaphyseal fracture of the radius, ulna, or both (including Monteggia and Galeazzi fracture-dislocations) that were treated with plate fixation. Patients were excluded from the study if they were lost to follow-up before radiographic documentation of bone union. The review identified 198 fractures that were eligible for inclusion. Fifteen fractures were excluded. INTERVENTION: The method of treatment of each fracture was open reduction and plate fixation with or without bone grafting. MAIN OUTCOME MEASUREMENT: Fracture union. RESULTS: The overall union rate in comminuted, nongrafted forearm fractures (open and closed) was 98% (99/101; 95% confidence interval: 93-100%). The union rate in closed, comminuted, nongrafted forearm fractures was 97% (74/76; 95% confidence interval; 91-100%). CONCLUSIONS: Open reduction and internal fixation of comminuted diaphyseal forearm fractures without bone grafting in this study produced union rates comparable to those reported for open reduction and internal fixation of comminuted forearm fractures with acute bone grafting. This study suggests that routine use of bone grafting in comminuted forearm fractures is not indicated.

The effect of single-pass reaming on tibial nail insertion load and stress.

This biomechanical study evaluated and compared the longitudinal and perpendicular stresses generated and the applied load required during the insertion of a tibial nail with three different insertion techniques. Insertion of a narrow-diameter nail using an unreamed technique generated significantly greater stress and required significantly greater applied load than either the single-pass reamed technique or a reamed technique. The single-pass reamed technique and the standard reamed technique were not significantly different from each other. This study biomechanically justifies the use of the single-pass reaming technique during the insertion of a narrow-diameter intramedullary nail in severe open tibial fractures. The use of this technique cannot be advocated until the biologic effect of single-pass reaming is more clearly defined.

Polytrauma care. The effect of head injuries and timing of skeletal fixation.

There is a substantial body of literature supporting early ( < 48 hours) fixation of long bone fractures in the patient with polytrauma. Early fixation reduces the complications of traction and recumbency, reduces pain, decreases the stimulus for a systemic inflammatory response, makes nursing care easier, makes the fracture outcome more predictable, and decreases health care costs. If hypotension and hypoxia are avoided, early fixation of long bone fractures does not increase the incidence of adverse cerebral events. The benefits (short and long term), if any, of early fixation of long bone fractures on the recovery from closed head injury remain poorly defined.

Management of complex acetabular fractures through single nonextensile exposures.

A review of 127 surgically treated acetabular fractures, treated between August 1986 and January 1991, using single nonextensile surgical exposures and indirect reduction techniques was conducted. There were 31 elementary and 96 associated fractures (Letournel). In 34 cases the fracture involved only one column and in nine cases an extensile or combined exposure was required, therefore these cases were excluded from the study. This left 84 complex fractures (involving two column) for review. In all cases either the anterior (ilioinguinal) or posterior (Kocher-Langenbeck) exposure was used. Indirect reduction of the involved and opposite column was achieved with either the Judet table, lateral trochanteric traction, or the femoral distractor. A satisfactory reduction was obtained in 90.5% (76 of 84) of the cases (concentric, gap < 3 mm, step off < 2 mm). The incidence of acute infection and heterotopic ossification was 0% and 2%, respectively.

Somatosensory evoked potential monitoring in the surgical treatment of acute, displaced acetabular fractures. Results of a prospective study.

A prospective protocol was developed to prevent iatrogenic nerve injury during the surgical treatment of acute, displaced acetabular fractures in 103 patients. The protocol included an independent neurologic evaluation and perioperative somatosensory evoked potential (SEP) monitoring (tibial division only). The incidence of posttraumatic nerve injury was 29% (30/103 patients). The incidence of postoperative nerve injury was 5% (5/103 patients): complete sciatic, 0; tibial division, 0; peroneal division, 5. Somatosensory evoked potential monitoring of the tibial division is effective in preventing injury to this division. If perioperative SEP monitoring is used, independent stimulation of the tibial and peroneal divisions is recommended. High-risk groups for perioperative injury to the sciatic nerve include those patients with significant posterior column or wall displacement or posttraumatic sciatic nerve injury.

Bicondylar intraarticular fractures of the distal humerus in adults.

Bicondylar intraarticular fractures of the distal humerus, because of their rarity and often associated significant displacement, comminution, and osteopenia, present the orthopedist with a difficult injury to reliably treat successfully. As with any displaced intraarticular fracture, the principles of anatomic restoration of the articular surface, stable fixation, and early motion are the optimal treatment goals. To obtain reproducible results, an established treatment protocol is required and is described in detail here. The average excellent-to-good results with surgical treatment for Type C fractures ("T" or "Y" bicondylar fractures) is 75% (range, 65-100%). Complications include heterotopic ossification (4%), infection (4%), ulnar nerve palsy (7%), failure of fixation (5%), and non-union (2%).

Heated lymphocytes express HLA-DR antigens despite their inability to stimulate in MLC.

We have utilized serological techniques and mixed lymphocyte culture (MLC) reactions to examine HLA-DR and HLA-D expression by heated (45 degrees C for 1 h) lymphocytes in order to study the functional relationship of these antigens. Heated lymphocytes do not stimulate proliferation of allogeneic lymphocytes in MLC, yet they express HLA-DR antigens. The fraction of peripheral blood lymphocytes (PBL) expressing DR is not altered by heating, nor is the staining intensity altered as detected by fluorescence microscopy. Alloantisera to "B cell alloantigens" recognize HLA-DR determinants on heated cells without any detectable change in either specificity or quantitative cytotoxic effects. Flow cytometry with monoclonal antibody demonstrates only minimal decrease in HLA-DR expression after heating. Thus stimulation in MLC requires more of the stimulating cell than the mere expression of HLA-DR.