David W. Lhowe

Immediate nailing of open fractures of the femoral shaft

Débridement of the wound and immediate reamed nailing were performed on sixty-seven patients who had an open fracture of the femoral diaphysis. Forty-two of these patients were followed for a minimum of twelve months (average, twenty-three months). Using the classification system of Gustilo and Anderson, there were fifteen (36 per cent) Grade-I, nineteen (45 per cent) Grade-II, and eight (19 per cent) Grade-III soft-tissue injuries. All of the fractures healed within four months after injury. The average flexion of the knee was 127 degrees and that of the hip, 129 degrees. At least 90 degrees of flexion was achieved in both joints of all patients. Perioperative complications included loss of fixation in four patients (10 per cent), infection of the wound in two patients (5 per cent), a wound seroma in two patients (5 per cent), and thrombophlebitis in one patient (2 per cent). Late complications were angular malunion in three patients (7 per cent), limb-length discrepancy in three patients (7 per cent), external rotation malunion in one patient (2 per cent), and sciatic-nerve palsy in one patient (2 per cent). We concluded that immediate intramedullary nailing of an open femoral fracture can be accomplished safely, with an acceptable rate of complications, given thorough débridement of the wound, proper equipment, and an experienced surgical team.

Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries.

The reason for the described clinical variability of acute compartment syndrome of the thigh, with high morbidity and mortality in some patients and an uncomplicated clinical course in others, is not known. To better define the clinical spectrum and factors determining the clinical course of this rare clinical entity, we did a retrospective multicenter study of 28 patients with 29 thigh compartment syndromes. The leading cause of acute thigh compartment syndrome was blunt trauma from motor vehicle accidents (46%) or contusion (39%). Pain with passive motion was present in all patients who were conscious, followed by paresthesia (60%), and paralysis (42%). The anterior compartment was involved most frequently with mean compartment pressure of 58 ± 3 mm Hg. Myonecrosis, sepsis, and need for skin grafting were observed more frequently in patients with ipsilateral femur fracture. Only 7% of patients with isolated thigh compartment syndromes had short-term complications compared with 57% of patients with ipsilateral femur fractures. The incidence of complications correlated with the time to fasciotomy. Mortality was limited to patients with high injury severity scores. The clinical spectrum of thigh compartment syndrome is comparable with that of other compartment syndromes and its clinical course is determined by its associated injuries.

Functional Outcome After Acute Compartment Syndrome of the Thigh

BACKGROUND Acute compartment syndrome of the thigh is an uncommon condition that is associated with a high rate of morbidity. Because of its rarity, limited information is available on the long-term functional outcome for patients with this condition and the factors that affect the clinical result. METHODS Eighteen patients with acute compartment syndrome of the thigh were evaluated at an average of sixty-two months after treatment. Functional outcome was evaluated by means of physical examination, isokinetic thigh-muscle testing, and validated functional outcome scores. RESULTS Long-term functional deficits were present in eight patients, and only five patients had full recovery of thigh-muscle strength. The persistent dysfunction was reflected in worse overall functional outcome scores. High injury severity scores, ipsilateral femoral fracture, prolonged intervals to decompression, the presence of myonecrosis at the time of fasciotomy, and an age of more than thirty years were associated with increased long-term functional deficits, persistent thigh-muscle weakness, and worse functional outcome scores. CONCLUSIONS Acute compartment syndrome of the thigh is often associated with considerable long-term morbidity. Several factors can affect the functional outcome, and knowledge of these factors can help in the development of a more effective clinical management strategy to reduce long-term morbidity.

Parturition-induced Pelvic Dislocation: A Report of Four Cases

OBJECTIVE To describe our experience with four cases of severe pelvic dislocation associated with difficult parturition. DESIGN Retrospective case series. PATIENTS Four patients, each with rupture of the symphysis pubis and sacroiliac joints during labor. All injuries were associated with significant initial pain and disability. All developed persistent symptoms related to the sacroiliac disruption. INTERVENTIONS The three patients who had presented acutely were freated with closed reduction and application of a pelvic binder. Two underwent closed reduction of their pelvic dislocation while anesthetized with a general anesthetic. One patient (N.A.), who presented late, had not been treated with a binder. RESULTS All four patients had persistent posterior pelvic (sacroiliac) pain. In two patients a postpartum neuropathy persisted. CONCLUSIONS Severe pelvic dislocations are rare during labor, with conservative treatment reported to be successful in most cases. The persistence of symptoms in our patients emphasizes the need for careful examination and follow-up of these rare injuries. Because the outcome in our patients was poor and results in the literature are equivocal, we suggest the consideration of an operative approach to treatment in patients with symphyseal diastasis of > 4.0 cm.

Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures

INTRODUCTION Bicondylar tibial plateau fractures can be treated with locked plating applied from the lateral side with or without additional application of a medial plate (dual plating). Recent studies demonstrate that these injuries can be sub-grouped based upon their morphology by computed tomography (CT). The purpose of this study is to evaluate the relationship between fracture pattern, method of fixation and loss of reduction in bicondylar tibial plateau fractures. PATIENTS AND METHODS Preoperative CT scans and postoperative plain films were evaluated on a consecutive series of bicondylar tibial plateau fractures. Fracture patterns were classified by CT. Angular alignment was measured immediately postoperatively and again at clinical and radiographic union to assess loss of reduction. RESULTS A total of 140 patients were studied. Sixty-six (47%) had a single large medial fragment with the articular surface intact, 19 (14%) had a medial articular fracture line with a mainly sagittal component and 55 (39%) had a coronal fracture through the medial articular surface. A total of 129 patients had been treated with lateral locked plating alone whilst 11 patients (all with a coronal fracture of the medial condyle) underwent dual plating. There was little loss of reduction (median subsidence 0.5°) when lateral locked plating was employed alone in patients with a single medial fracture fragment or with a sagittal medial fracture line. When lateral locked plating was used in the presence of a medial coronal fracture line, there was a significantly higher rate of subsidence (median 2.0°) compared to those with no medial fracture line (p=0.002). Patients with coronal fracture lines treated with dual plating had significantly less loss of reduction that those treated with lateral locked plating (p=0.01). CONCLUSIONS Most patients with bicondylar tibial plateau fractures do well when treated with lateral locked plating. However, those with a medial coronal fracture line tend to have a higher rate of subsidence and loss of reduction when lateral locked plating is employed alone. These fractures may be better treated with dual plating if the soft tissues allow. LEVEL OF EVIDENCE Level III (retrospective comparative study).

Delayed presentation of acute compartment syndrome after contusion of the thigh.

Acute compartment syndrome has been described as a result of thigh contusion in several contact sports, and emergent fasciotomy has routinely been recommended. However, recent data suggest that thigh contusions in athletes presenting with isolated elevation of compartment pressures in the absence of neurovascular deficits may be treated expectantly. We describe a case of anterior thigh contusion, which initially presented with isolated compartmental hypertension without neurovascular symptoms. Under nonoperative treatment the patient developed delayed acute compartment syndrome from persistent muscular hemorrhage ten days after the initial trauma, requiring operative treatment. This case demonstrates that expanding hematoma formation may result in delayed increase of intramuscular pressures and compromise of myoneural perfusion in patients with severe thigh contusions. Early evacuation of the hematoma may help to prevent late development of compartment syndrome and reduce the risk for long-term complications.

The management of femoral diaphyseal nonunions

OBJECTIVE To assess the efficacy of treatment and develop an algorithm for management of nonunions of the femoral diaphysis. STUDY DESIGN Retrospective. SETTING University hospital. METHODS Forty-four patients treated at one institution for nonunion of the femoral diaphysis were studied. Thirteen of these patients had a history of infection. After debridement (where appropriate) and repair of the femoral nonunion, follow-up averaged twenty-eight months (range, 24 to 108 months). All patients were examined at final follow-up. RESULTS Thirty-three patients achieved union after one procedure, and eight patients achieved union after additional procedures. One patient underwent above-knee amputation, and two patients remained ununited at the time of their final follow-up. Time to union averaged 11.8 months. Seventeen patients healed with more than two centimeters of shortening, and ten patients lost more than 30 degrees of knee flexion. CONCLUSION Established femoral diaphyseal nonunions can be treated effectively, even in the presence of chronic sepsis. Selective use of a vascularized fibula transfer has proven beneficial in addressing intercalary defects. Plate fixation, with or without a vascularized fibula transfer, has been the predominant mode of skeletal stabilization in more complex reconstructions.

Congenital intraspinal lipomas: clinical presentation and response to treatment

A retrospective review of 29 patients with surgically treated intraspinal lipomas was conducted in a determination of their manner of presentation and response to treatment. The average age at the time of diagnosis for the entire group was 12.8 years. Only five patients were neurologically normal by clinical examination at the time of diagnosis, and these five patients were all <6 months old. Orthopedic intervention was judged successful in each of the 11 foot procedures done after surgery on the lipoma, but in only two of the five foot procedures done before such surgery. We conclude that consideration of intraspinal lipoma is worthwhile in several circumstances, including pediatric foot deformities.

Orthopaedic Care Aboard the USNS Mercy During Operation Unified Assistance After the 2004 Asian Tsunami: A Case Series

On December 26, 2004, a 9.0-magnitude earthquake occurred off the northwest coast of Sumatra, Indonesia. The subsequent tsunami caused unprecedented destruction throughout the Indian Ocean basin1. In eleven nations, millions were injured and/or displaced and, although estimates vary, as many as 300,000 lives may have been lost2-4. Within days after this natural disaster, hundreds of humanitarian organizations and thousands of military troops from several countries mobilized to offer assistance5-7. The U.S. military response came in the form of Operation Unified Assistance, a mission of humanitarian aid and disaster relief8. Within days, the U.S. Navy carrier strike group led by the USS Abraham Lincoln and the expeditionary strike group led by the USS Bonhomme Richard were sent to provide aid to heavily damaged areas. Numerous U.S. military aircraft were also dispatched to facilitate the safe movement of personnel, food, medicine, and drinking water9,10. In addition to providing immediate relief services, the U.S. Navy deployed a hospital ship to the region. The USNS Mercy departed San Diego, California, on January 5, 2005, en route to the Aceh province of Sumatra, Indonesia. The mission of the USNS Mercy was to conduct medical humanitarian aid and disaster relief operations in support of the government of Indonesia to reduce suffering and improve public health. The Mercy crew of health-care providers included medical and surgical staff from the U.S. Navy and officers from the U.S. Public Health Service. To augment the Navy Medical Corps, approximately 100 civilian volunteer physicians, nurses, and technologists from the non-governmental organization Project HOPE were included11, making this the first mission in history to utilize civilian medical personnel aboard a U.S. Navy vessel. From February 5 through March 16, 2005, the USNS Mercy provided …

Retrograde nailing of femur fractures in patients with myelopathy and who are nonambulatory

The authors studied 10 consecutive patients with closed femoral shaft or supracondylar fractures who were nonambulatory and who were treated by reamed retrograde intramedullary nailing via an intercondylar notch approach. The study consisted of five women and five men with an average age of 60.7 years (range, 40-89 years). Six patients had spinal cord lesions, one had a brain injury, one had cerebral palsy, one had multiple sclerosis, and one had progressive myelopathy. Three fractures were supracondylar, and seven fractures involved the mid-distal diaphysis. The average time of surgery was 110 minutes (range, 70-225 minutes) with an average estimated blood loss of 288 mL (range, 150-400 mL). There were two postoperative deaths (at 15 days and 2 months, respectively) after the procedure that were attributable to pneumonia. The remaining eight patients were observed for an average of 13 months (range, 6-20 months) after surgery. All fractures healed as evaluated radiographically. Retrograde intramedullary nailing is a simple, safe, and effective alternative to nonoperative treatment for femoral shaft or supracondylar fractures in patients who are nonambulatory. Stabilization by this method allows fracture healing and rapid return of patients to their previous level of function. There were no nonunions, malunions, significant shortening, implant failure, or wound infections.