Antegrade intramedullary nailing of the humerus complicated by heterotopic ossification of the deltoid: a case report.

A case of antegrade nailing of the humeral shaft in a polytrauma patient was complicated by heterotopic ossification of the lateral deltoid muscle and severe loss of shoulder motion. The patient did not respond to physiotherapy alone and was successfully managed by excision of the heterotopic bone and adjunctive radiation therapy.

A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft.

OBJECTIVES: To determine if there are differences in healing, complications, or number of procedures required to obtain union among open and closed tibia fractures treated with intramedullary (IM) nails inserted with and without reaming. DESIGN: Prospective, surgeon-randomized comparative study. SETTING: Level One trauma center. PATIENTS: Ninety-four consecutive patients with unstable closed and open (excluding Gustilo Grade IIIB and IIIC) fractures of the tibial shaft treated with IM nail insertion between November 1, 1994, and June 30, 1997. INTERVENTION: Interlocked IM nail insertion with and without medullary canal reaming. MAIN OUTCOME MEASURES: Time to union, type and incidence of complications, and number of secondary procedures performed to obtain union. RESULTS: For open fractures, there were no significant differences in the time to union or number of additional procedures performed to obtain union in patients with reamed nail insertion compared with those without reamed insertion. A higher percentage of closed fractures were healed at four months after reamed nail insertion compared with unreamed insertion (p = 0.040), but there was not a difference at six and twelve months. More secondary procedures were needed to obtain union after unreamed nail insertion for the treatment of closed tibia fractures, but the difference was not statistically significant given the limited power of our study (p = 0.155). Broken screws were seen only in patients treated with smaller-diameter nails inserted without reaming, and the majority occurred in patients who were noncompliant with weight-bearing restrictions. There were no differences in rates of infection or compartment syndrome. CONCLUSION: Our findings support the use of reamed insertion of IM nails for the treatment of closed tibia fractures, which led to earlier time to union without increased complications. In addition, canal reaming did not increase the risk of complications in open tibia fractures.

Retrograde nailing of humeral shaft fractures: a biomechanical study of its effects on the strength of the distal humerus.

OBJECTIVES: The purpose of this study was to evaluate the loss of strength in the distal humerus that resulted from the creation of two different entry portals used for retrograde humeral nailing. DESIGN: Nine pairs, treated as blocks of size two, of fresh frozen humeri from individuals free of musculoskeletal disease were randomly divided into three groups in a balanced incomplete block experimental design. INTERVENTION: The specimens were tested intact (control) or with an entry portal drilled in either the distal metaphyseal triangle or the proximal slope of the olecranon fossa. Two of these three conditions were applied to each pair of the bones. Therefore, three pairs of bones accommodated testing of all possible combinations of the two treatments. All specimens were tested in torsion at a rate of 30 degrees per second until failure or fracture. RESULTS: The creation of an entry portal reduced the ultimate torque to 63 percent of that of the intact specimens (p = 0.044) and the energy absorbed to failure to 27 percent of that of the intact specimens (p = 0.039). The metaphyseal entry portal reduced the torque to failure to 71 percent of that of the intact specimens (p = 0.143) and the energy absorbed to failure to 37 percent of that of the intact specimens (p = 0.073), The olecranon fossa entry portal reduced the torque to failure to 55 percent of that of the intact specimens (p = 0.035) and the energy absorbed to failure to 18 percent (p = 0.058) of that of the intact specimens. CONCLUSIONS: Surgeons should be aware of the loss of strength in the distal humerus after retrograde humeral nailing. This is especially important when prescribing postoperative mobilization in which the upper extremities will be used for weight-bearing in either transfers or ambulation.

Update on the management of open fractures of the tibial shaft.

A retrospective study of 133 open tibial fractures in 129 patients treated at the Hennepin County Medical Center between 1986 and 1993 was done. The results of the treatment protocol in this patient group is presented and the current classification schemes, prevention of infection, debridement, antibiotics, soft tissue reconstruction, fracture stabilization methods, bone grafting, and exchange nailing are discussed. Recent studies that have documented interobserver disagreement in the classification of open fractures underscore the difficulties encountered in the initial assessment and treatment of open tibial shaft fractures. Despite repetitive and aggressive debridement, a certain number of fractures will remain contaminated and become infected. Infection after these severe injuries is probably multifactorial, and its prevention requires that the surgeon diligently adhere to the imperatives of open fracture care.

Blood conservation in hip trauma.

Patients with hip or pelvic fractures experience significant blood loss as a result of the fracture and from the surgery that subsequently is performed. The emergent and unplanned nature of fracture surgery precludes the use of preoperative blood donation and the optimization of chronic medical problems. Blood transfusion frequently is required to maintain adequate tissue O2 delivery in these injured patients. However, the administration of allogeneic blood causes other problems, including a well documented increase in the risk of infectious complications. Perioperative measures to minimize blood loss such as hypotensive anesthesia and red blood cell salvage are important, but often are inadequate to prevent the need for blood transfusion. Recently, erythropoietin therapy has been shown to stimulate hematopoiesis in patients with hip fractures. The authors discuss their experience with blood loss management in these patients with hip injuries, including aggressive Fe replacement therapy and the use of recombinant human erythropoietin.

Techniques for the removal of broken small-diameter tibial nails: a report of two cases.

The availability of small-diameter interlocking nails for unreamed applications has expanded the indications for intramedullary nailing of open tibial shaft fractures. Smaller diameter nails that are inserted without reaming are mechanically weaker than the larger-diameter nails that are inserted after intramedullary reaming. Potentially, nails with a smaller diameter will fail at a higher rate, creating unique difficulties associated with their removal. This article presents two cases that illustrate solutions to those problems.

Patellar tendon rupture. Description of a simplified operative method for a current therapeutic problem.

A simple operative method for the treatment of patellar tendon rupture is introduced. The operative procedure is described and we present the short-term results of the first seven patellar tendon ruptures that have been treated accordingly at our clinic. The technique is easily reproducible and utilizes a minimum of foreign body implant. A secondary procedure for removal of suture material is rarely necessary.

Injuries of the knee associated with fractures of the tibial shaft. Detection by examination under anesthesia: a prospective study.

Ligamentous injuries of the ipsilateral knee have been documented in association with 25 to 35 percent of fractures of the femoral shaft. However, to our knowledge, a similar association between ligamentous injuries of the knee and fracture of the tibial shaft has not been studied prospectively. To determine if there was such an association, a prospective study was conducted in which the knees of fifty patients who had a fracture of the ipsilateral tibial shaft of varying severity were examined manually while the patient was under general anesthesia. Eleven patients (22 percent) were found to have sustained an injury to at least one ligament of the knee that resulted in increased laxity of 2+ or more. One knee had dislocated. On the basis of the results of this study, we believe that, after stabilization of a fracture of the tibial shaft, it is essential to examine the knee thoroughly to identify any associated ligamentous injuries.

Calcium dependence of neuromuscular events in esophageal smooth muscle of the opossum.

Intramural nerves in smooth muscle strips from opossum esophagus were stimulated electrically to cause contractions of longitudinal body muscle, off responses of transverse body muscle and relaxations of sphincter muscle. Krebs solution was modified by calcium removal by strontium substitution for calcium, by adding magnesium, and by adding nitroprusside. Longitudinal muscle contractions were abolished by calcium removal and by excess magnesium; they were unaffected by nitroprusside; strontium could not replace calcium. Off responses were abolished by calcium removal and by excess magnesium; they were depressed by nitroprusside; strontium effectively replaced calcium. Resting active tension in sphincter strips was partly reduced by calcium removal and by excess magnesium; it was abolished by nitroprusside; strontium could not replace calcium. Relaxations in sphincter strips were unaffected by all experimental conditions. Longitudinal contractions, off responses, and resting active tension of the sphincter represent different kinds of calcium activation of muscle. The excitatory nerves (which are cholinergic) in longitudinal muscle are calcium dependent, the nerves that produce off responses may not be, and the nerves that relax the sphincter are not.