Bilateral femoral neck stress fractures in an amenorrheic athlete.

Stress fractures in athletes rarely involve the femoral neck. This report described the diagnosis and treatment of bilateral femoral neck stress fractures in a 30-year-old amenorrheic triathlete who is lactose intolerant and has a low caloric intake. The possibility of fatigue fracture should be considered in patients who have pain in the lower extremities that is exacerbated by activity, especially if they have hormonal or nutritional disorders.

Functional outcome analysis of operatively treated malleolar fractures.

OBJECTIVES: Assessment of functional outcome after malleolar fractures. DESIGN: Retrospective call-back review of 40 patients who agreed to assessment 8-24 months after malleolar fractures. SETTING: Acute care hospital/Level 1 trauma center with university-based orthopaedic residency. PTS/PARTICIPANTS: 1) 10 skeletally mature patients who agreed to a telephone request to return for review 8-24 months after isolated malleolar fractures (36 44B2.2, 3 44A2.3, 1 44C2.2). All had healed without apparent complications. 2) Control group of 40 age matched healthy individuals without ankle problems. INTERVENTION: ORIF with standard AO/ASIF techniques. MAIN OUTCOME MEASUREMENTS: Ankle score of Olerud and Molander, UCLA Activity Score, Pedometer count of average number of steps per day. RESULTS: Patients had a mean Ankle Score of 72 (+/-19.3) vs. 100 (+/-0) for controls (p < .01). The UCLA Activity Score averaged 6.0 (+/-1.95) for the patients vs. a mean of 9.43 (+/-1.0) for controls (p < .01). Patients took an average of 4,838 steps per day (+/-3,252) vs an average of 7,607 steps per day (+/-2,859) by controls (p < .01). CONCLUSIONS: Significant impaired function persists for most patients 8-24 months after malleolar fractures.

An experimental model of femoral condylar defect leading to osteoarthrosis.

The acute treatment of articular step-off injuries is based largely on reduction criteria, because the presence of residual incongruity has been correlated with the development of posttraumatic arthrosis (PTA). However, this association has not been demonstrated on a prospective basis. Using the rabbit femoral condyle, we developed a surgical model of articular condylar defect without sacrificing the axial alignment or inherent stability of the knee joint. Twenty weeks after the creation of 5-mm femoral condylar defects, progressive osteoarthritic changes were confirmed by radiographic, histological, and biochemical parameters. Osteophytes were observed on the medial aspect of operated knee joints in 67% of cases. Femoral and tibial articular cartilage at the site of the condylar defect exhibited fibrillation, hypocellularity, and severe loss of safranin-O staining. Focal areas of cartilage were denuded or replaced by pannus. In no case was femoral congruity restored by cartilage repair. Statistically significant decreases in proteoglycan content were demonstrated for cartilage sampled from the weight-bearing region of the condylar defect and from the tibial surface directly beneath it. These changes resemble those arising from previously reported models of osteoarthrosis. We present the model as a valid tool for the study of articular condylar defect and its role in the development of PTA.

Localized nodular synovitis of the ankle: a case report.

Localized nodular synovitis of the ankle in a 52-year-old male was treated with excision. Extensive articular destruction of the talar dome was noted. The diagnosis was confirmed by histology. A report of a similar lesion was not found.

Early complications in the management of open femur fractures: a retrospective study.

Fifty patients with 53 open fractures of the femur were reviewed retrospectively. There were three subtrochanteric, 32 shaft, and 18 supraintercondylar fractures. Eleven were type I open fractures, 20 were type II open fractures, and 22 were type III open fractures. After initial debridement, 33 fractures had immediate internal fixation, nine had delayed internal fixation, one had external fixation, and 10 were treated with traction and cast bracing. Nine (16%) fractures, two type II and seven type III, developed deep infection. Five infections persisted at 6 months. Immediate internal fixation was followed by deep infection in one of 22 type I or II fractures and six of 11 type III fractures. There were five nonunions and seven delayed unions. Five of 44 uninfected and seven of 10 infected fractures had delayed union or nonunion. In this series, most patients with type III open femur fractures had severe associated multiple trauma. Immediate internal fixation was associated with greater local complications. We have concluded that immediate internal fixation of type III femoral fractures is only relatively indicated and must be applied with caution.

Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum.

The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) has been charged to devise injury severity scores for individual organs to facilitate clinical research. Our first report (1) addressed O.I.S.'s for the Spleen, Liver, and Kidney; the following are proposed O.I.S.'s for Pancreas (Table I), Duodenum (Table II), Small Bowel (Table III), Colon (Table IV), and Rectum (Table V). The grading scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. We emphasize that these O.I.S.'s represent an initial classification system which must undergo continued refinement as clinical experience dictates.

Pelvic ring injuries.

Many problems may complicate the treatment of pelvic fractures. Thorough evaluation of the whole patient, all local structures, and the skeletal injury itself is essential. Continued bleeding due to unstable pelvic ring injuries is most effectively controlled by prompt anterior external fixation. Posterior shearing injuries are poorly stabilized by external fixation, and require additional treatment. Especially when significant deformity exists, or when the posterior injury is primarily ligamentous, open reduction and internal fixation are likely to be beneficial.

Closed unstable fractures of the tibia.

Unstable closed tibial fractures are those with major soft tissue damage, complete displacement, significant comminution, direct force mechanism, or articular surface involvement. Although the "average" tibial fracture is effectively managed without surgery, patients with such injuries frequently have prolonged convalescence and unsatisfactory anatomic and functional results. This review of recent literature reveals that in appropriately chosen patients, surgical fixation of unstable closed tibial fractures produces faster recovery and less residual disability or deformity. This is especially true when intramedullary nailing is indicated, as in transverse, short oblique, or segmental fractures. Plate and screw fixation is preferable for metaphyseal fractures. External fixation may be safest when soft tissue crushing is extensive, especially if fasciotomy is required.

Subtrochanteric-intertrochanteric femoral fractures.

Subtrochanteric fractures can be managed effectively with newer techniques and implants. If the proximal fragment is intact and includes the lesser trochanter, an interlocking intramedullary nail is indicated. If there is inter-subtrochanteric comminution, a screw-plate device with bone graft, or a Zickel nail should be used.

Computed tomography of thoracic and lumbar spine injuries.

CT scans of 73 patients with acute thoracic/lumbar spine injuries from T3 to L5 were reviewed. Injuries were classified as burst fractures (48), fracture-dislocations (ten), wedge compression fractures (11), and seatbelt-type injuries (four). Thirty-one (42%) had motor deficits due to spinal cord or nerve root damage. Such neurologic deficits were present in all patients with fracture-dislocations, and 60% of those with burst fractures. Seven patients, four initially normal, developed progressive neurologic impairment early after injury. Burst fractures, one with dislocation, were the spinal injury associated with each progressive deficit. Burst fractures at T12 or L1 with 50% or more decrease of the mid-sagittal neural canal diameter had a significant risk of neurologic involvement, and of progressive deficit. CT scans demonstrate vertebral column damage well, and help identify those patients at risk of acute neurologic compromise.