Bartolome T Allende

Ununited Diaphyseal Forearm Fractures with Segmental Defects: Plate Fixation and Autogenous Cancellous Bone-Grafting

BACKGROUND With current techniques of plate-and-screw fixation, diaphyseal nonunions of the radius and ulna are unusual. The few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions that are associated with osseous defects. We reviewed the rate of union and the functional results in association with the use of plate-and-screw fixation and autogenous cancellous (nonstructural) bone grafts. METHODS Thirty-five patients with an atrophic ununited diaphyseal fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting. A segmental osseous defect with an average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty of the original fractures had been open. Eleven patients had had treatment of a deep infection before referral to us. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients. RESULTS The atrophic nonunion was associated with an open fracture in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation of the forearm in nine, and infection in eleven. All fractures healed without additional intervention within six months. Two patients had a subsequent Darrach resection of the distal part of the ulna for the treatment of arthrosis of the distal radioulnar joint. After an average duration of follow-up of forty-three months, the final arc of motion averaged 121 degrees in the forearm, 131 degrees at the elbow, and 137 degrees at the wrist, with an average grip strength of 83% compared with that of the contralateral limb. According to the system of Anderson and colleagues, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion). CONCLUSIONS When the soft-tissue envelope is compliant, has limited scar, and consists largely of healthy muscle with a good vascular supply, autogenous cancellous bone-grafting and stable internal plate fixation results in a high rate of union and improved upper limb function in patients with diaphyseal nonunion of the radius and/or ulna.

Posttraumatic one-bone forearm reconstruction. A report of seven cases.

Hey Groves1 first described the one-bone forearm in 1921, and subsequently several other studies on the topic have been published2-11. The indications for one-bone forearm reconstruction include atraumatic instability, previous bone tumor resection or congenital deformity (type-2 cases according to the system of Peterson et al.3), or posttraumatic lesions (type-1 cases). When chosen for the correct indication, this reconstructive technique can provide a stable forearm with good functional and cosmetic results as well as patient satisfaction4. Despite multiple published series, there is no clear agreement regarding the indications for, best operative technique for, or the long-term results of the creation of a one-bone forearm following injury. We report seven cases of complex combined skeletal and soft-tissue posttraumatic lesions of the forearm, each of which was successfully treated by conversion to a one-bone forearm with use of intramedullary fixation and autogenous bone graft. We retrospectively reviewed the results of seven patients who had been treated, between 1985 and 1997, by the creation of a one-bone forearm to address severe combined posttraumatic osseous and soft-tissue lesions of the forearm (Table I). They were informed verbally that data concerning their cases would be submitted for publication. The mean age of the patients at the time of the procedure was twenty-nine years (range, sixteen to thirty-eight years), and the dominant side was reconstructed in four patients. Five patients were manual laborers and had a work-related injury. One was an architect who was injured in an airplane accident, and one was a sixteen-year-old patient who had sequelae of an injury sustained in a farm machine accident at the age of three years. Both bones were affected in six patients, and only the radius was affected in one. View this table: TABLE I Patient Data All fractures were initially open and secondary to …

Trombosis de la arteria axilar en el posquirúrgico de una fractura del húmero proximal Tratamiento con stent autoexpansible

Una paciente de 76 años, con antecedentes de hipertensión e hipotiroidismo, consultó por dolor e impotencia funcional después de una caída desde su propia altura e impacto del hombro izquierdo contra el suelo, en ocasión de un asalto. En el examen físico no se evidenció compromiso neurovascular del miembro (pulsos periféricos presentes, sensibilidad conservada, relleno capilar conservado). La radiografía de hombro (frente, perfil transtorácico y Lammy) mostró una fractura-luxación del húmero proximal multifragmentaria (AO 11–C3) (Fig. 1). Los estudios de laboratorio y la valoración prequirúrgica estaban dentro de los parámetros normales. La paciente fue intervenida quirúrgicamente cinco días después de ocurrida la fractura (durante ese período no se evidenció alteración neurovascular alguna); se le realizó un reemplazo parcial de hombro cementado por abordaje deltopectoral; la remoción de la cabeza humeral, en estrecho contacto con las estructuras neurovasculares, se realizó luego de la desinserción del tendón del músculo subescapular mediante maniobras digitales suaves. En el intraoperatorio se le administró una unidad de glóbulos rojos sedimentados. En el posoperatorio inmediato se evidenció palidez en el miembro superior operado y pulsos presentes pero débiles, por lo que se efectuó una ecografía Doppler que registró ausencia de flujo en la arteria humeral, arteria subclavia con flujo francamente disminuido y signos a favor de una obstrucción en la arteria subclavia distal, unión subclavioaxilar izquierda, en el sitio donde la cabeza humeral luxada se había posicionado después del accidente. Se realizó una angiografía del miembro superior izquierdo con un catéter diagnóstico JR 3.5 6F, en la que se visualizó una obstrucción total de la arteria axilar izquierda, con flujo distal TIMI 0 (TIMI: trombólisis en infarto de miocardio. Sistema de puntaje de 0 a 3, haciendo referencia a niveles de flujo sanguíneo durante la angiografía percutánea. TIMI 0: sin perfusión, TIMI I: penetración sin perfusión, TIMI II: reperfusión parcial, TIMI III: perfusión completa). Se avanzó un catéter guía JR 8 French a través del cual se introdujo un microcatéter rapid transit sobre una guía 0.014 BMW y se logró transponer la lesión obstructiva de la arteria axilar (Fig. 2). La imagen angiográfica, luego de transponer la obstrucción, mostró una disección localizada de la