Complications associated with open calcaneus fractures.

BACKGROUND: Literature on open calcaneus fractures is limited and inconsistent. This study's purpose was to report complications such as osteomyelitis, amputations, and soft tissue infections in open calcaneus fractures that were treated at a Level I Trauma Center. METHODS: From January 1995 through December 2007, 1,157 calcaneus fractures were identified with 127 fractures being open (11.0%). Average followup time was 9.1 (range, 2 to 53) months. All open fractures were treated by a similar protocol of intravenous (i.v.) antibiotics, emergent irrigation and debridement (I&D), initial fracture stabilization if possible, subsequent I&Ds as needed, and delayed definitive fixation. One hundred fifteen open calcaneus fractures in 112 patients had sufficient followup for study inclusion. For this study complications were classified into four categories: superficial infections, deep infections, osteomyelitis, and amputations. RESULTS: Medial based wounds occurred in 63 (54.8%) fractures. The overall complication rate was 23.5% with 16 fractures (13.9%) requiring a reoperation. Eleven (9.6%) fractures experienced superficial wound infection and 14 (12.2%) had deep wound infection. Six (5.2%) amputations were required with three being for either soft tissue infection or wound necrosis. Culture-positive osteomyelitis occurred in six (5.2%) patients. CONCLUSION: Utilizing a standardized protocol, open calcaneus fractures were found to have a lower complication rate than has been previously reported.

A rare trifocal presentation of Clostridium septicum myonecrosis.

Gas gangrene or clostridial myonecrosis is a rare, life threatening infection of the muscle that is typically associated with recent surgery or trauma. It usually affects older individuals who suffer from vascular insufficiency or who are immunocompromised. The typical pathogen is Clostridium perfringens. Atraumatic gas gangrene caused by Clostridium septicum is less common and has a unique association with colon cancer. This condition aggressively spreads through the muscular tissue and often culminates in septic shock. Fatality occurs within 48 hours if left untreated yet, despite emergent treatment the mortality rate is >50% without any comorbidities. Given the propensity to occur in the extremities the orthopedic surgeon must be familiar with its presentation, diagnosis, and treatment. This article presents a case of a 16-year-old girl who presented to the emergency room with an 18-hour history of malaise and progressive right arm discomfort and swelling. The identification and emergent treatment of necrotizing soft tissue infections is important and often falls on the orthopedic surgeon, especially when isolated to the extremities. Subtle initial presentation and rapid progression of the infection are classic findings of necrotizing soft tissue infections, particularly with clostridial myonecrosis and necrotizing fasciitis. Clostridium myonecrosis is a rare orthopedic condition with high mortality. Early diagnosis and debridement is imperative. A team approach to managing these patients postoperatively is necessary. The use of hyperbaric oxygen can be considered, however, it may not be readily available and its use is unproven in human studies. Due to its high mortality, one should err on the side of more aggressive resective/ablative surgery.

Displaced type II extension supracondylar humerus fractures: do they all need pinning?

The treatment of a displaced type II extension supracondylar humerus fracture is controversial. Many authors recommend that all displaced type II fractures be surgically pinned. The purpose of this study was to determine the success of reduction and casting (without pinning) in maintaining the alignment of type II fractures. Of the 25 elbows that underwent an initial reduction in the emergency room, 18 (72%) maintained alignment. Seven fractures lost position, and five of the seven patients underwent secondary reduction and pinning. Twenty-three of the 25 (92%) elbows had a satisfactory outcome and 2 of the 25 (8%) had an unsatisfactory outcome according to the Flynn criteria. All 24 patients were satisfied with the treatment on a satisfaction survey. An attempt at closed reduction and casting, with selective pinning of the fractures that lose position, appears justified if close follow-up can be maintained.

Acute backpack injuries in children.

OBJECTIVE: To identify the most common mechanisms and sites of injury associated with book backpacks in school-aged children, who present to the emergency department. This should help with the development of backpack injury prevention strategies. DESIGN: A descriptive analysis of The National Electronic Injury Surveillance System (NEISS) of the US Consumer Product Safety Commission (CPSC) National Injury Information Clearinghouse data on backpacks. SETTING: One hundred emergency department departments throughout the United States that participate in NEISS data collection served as the setting. PARTICIPANTS: All children between 6 and 18 years old who were recorded in the NEISS database with a backpack-related injury were studied. METHODS: Patients were identified by review of the NEISS data from 1999-2000. We separated patient data by age, sex, location of injury, and mechanism of injury. RESULTS: There were 247 children with backpack injuries. The mean age was 11.8 years, and 50% were male. The most common injury location was the head/face (22%) followed by the hand (14%), wrist/elbow (13%), shoulder (12%), and foot/ankle (12%). The back ranked sixth (11%). Of these back injuries, 59% were associated with carrying a backpack. The most common mechanism for injury was tripping over the backpack (28%), followed by wearing (13%), and getting hit by the backpack (13%). CONCLUSIONS: Although the CPSC data on backpack injuries is frequently quoted in articles relating backpacks with back injury, 89% of backpack injuries in our study do not involve the back. Our study does not support the hypothesis that back injury is the major problem with book backpacks in the emergency department setting.