Enes Kanlic

Advantages of submuscular bridge plating for complex pediatric femur fractures.

Conventional treatments of pediatric femoral shaft fractures may result in an unacceptable rate of complications, especially in complex fractures. These fractures include high-energy injuries resulting in unstable fracture patterns, fractures in the proximal or distal third, and fractures occurring in large or multiply injured children. Our goal was to evaluate whether a minimally invasive submuscular bridge plating technique provides stability for early functional treatment (without protective casting or bracing) and predictable healing. Fifty-one patients with an average age of 10 years were studied. Sixty-seven percent had high-energy injuries and 55% had unstable fracture patterns. With an average followup of 14.2 months, all fractures united with excellent clinical results. Two (4%) significant complications occurred: fracture of one 3.5-mm LC-DCP Ti plate, and refracture of a pathologic fracture after early plate removal. Four patients (8%) had a leg-length discrepancy ranging from 23-mm short to 10-mm long. The average operative time was 106 minutes, with average fluoroscopy time of 84 seconds. Procedures were done by 15 surgeons in five university medical centers. This technique offers the advantage of adequate stability for early functional treatment and predictable healing with maintenance of length and alignment for all pediatric femoral shaft fractures.

Posterolateral Approach for Treatment of Posterior Malleolus Fracture of the Ankle

Treatment of the posterior malleolus has been debated among orthopedic surgeons. Most orthopedic surgeons will fix the posterior malleolus if it is larger than 25% to 30% of the distal articular surface. The most common method of fixation of the posterior malleolus is by indirect reduction and anteroposterior screws. In the present study, we describe the technique and results of treatment of the posterior malleolus by direct reduction through the posterolateral approach to the ankle. The decision to fix the posterior malleolus was determined by its size and displacement. A total of 12 consecutive patients underwent the posterolateral approach to reduce the posterior malleolus, and these were fixed by posterior plate. Two patients were lost to follow-up in the early postoperative period (both after 2 months). No deep infection or wound dehiscence occurred. Ten patients had adequate (<2-mm displacement of the articular surface) radiologic reduction at the final follow-up visit. There were 2 cases of 2 mm or more of articular surface displacement at the final follow-up visit (1 patient had 2-mm displacement noted in the immediate postoperative period and 1 patient had adequate reduction in the beginning but was displaced with additional follow-up). The posterolateral approach to the ankle is a useful tool to treat certain cases of posterior malleolus fracture. It allows good visualization and stable fixation of the posterior malleolus.

Acute morbidity and complications of thigh compartment syndrome: A report of 26 cases

BackgroundTo describe the patient population, etiology, and complications associated with thigh compartment syndrome (TCS). TCS is a rare condition, affecting less than 0.3% of trauma patients, caused by elevated pressure within a constrained fascial space which can result in tissue necrosis, fibrosis, and physical impairment in addition to other complications. Compartment releases performed after irreversible tissue ischemia has developed can lead to severe infection, amputation, and systemic complications including renal insufficiency and death.MethodsThis study examines the course of treatment of 23 consecutive patients with 26 thigh compartment syndromes sustained during an eight-year period at two Level 1 trauma centers, each admitting more than 2,000 trauma patients yearly.ResultsPatients developing TCS were young (average 35.4 years) and likely to have a vascular injury on presentation (57.7%). A tense and edematous thigh was the most consistent clinical exam finding leading to compartment release (69.5%). Average time from admission to the operating room was 18 +/- 4.3 hours and 8/23 (34.8%) were noted to have ischemic muscle changes at the time of release. Half of those patients (4/8) developed local complications requiring limb amputations.ConclusionTCS is often associated with high energy trauma and is difficult to diagnose in uncooperative, obtunded and multiply injured patients. Vascular injuries are a common underlying cause and require prompt recognition and a multidisciplinary approach including the trauma and orthopaedic surgeons, intensive care team, vascular surgery and interventional radiology. Prompt recognition and treatment of TCS are paramount to avoid the catastrophic acute and long term morbidities.

Deep venous thrombosis and pulmonary embolism after surgical treatment of ankle fractures: a case report and review of literature.

Deep vein thrombosis and pulmonary embolism are major complications that can occur after ankle injuries. We present the case of a patient with an ankle fracture who developed deep vein thrombosis and massive pulmonary embolism after surgical treatment of the ankle fracture. A review of the published data on this topic is presented. The treating physician should assess patients with ankle fracture for their risk of developing a venous thromboembolic event on an individual basis and provide thromboprophylaxis for those with an increased risk of developing such complications.

Computer navigation in orthopedic trauma: safer surgeries with less irradiation and more precision.

Exposure of patients and practitioners to ionizing radiation for diagnostic and therapeutic purposes has become the norm rather than the exception. This article discusses the findings from a literature review of intraoperative risks from ionizing radiation to patients and surgeons and the validity of substituting the conventional intraoperative fluoroscopy with computer-assisted orthopedic surgery (CAOS) in orthopedic trauma surgery. Diversity of study designs and measurements exists in reporting intraoperative ionizing radiation, making direct study comparisons difficult. CAOS can effectively reduce the amount of radiation exposure. There are definite advantages and disadvantages for using CAOS in the field of orthopedic trauma. Implementation of CAOS may hold the answer to better patient and surgeon intraoperative radiation safety with decreased operative time and increased procedure precision. The increased safety for patients and surgeons is a critical consideration in recommending CAOS in trauma surgery.

Minimally Invasive (Sinus Tarsi) Approach for Open Reduction and Internal Fixation of Intra-Articular Calcaneus Fractures in Children: Surgical Technique and Case Report of Two Patients

Calcaneus fractures in children differ from those in adults. Most calcaneus fractures in children can be managed nonoperatively, with good long-term results expected. The width and height of the calcaneus can remodel with time in children. Recently, there has been a trend toward operative treatment of displaced intra-articular fractures of the calcaneus in children to correct the articular deformity. Studies of calcaneal fracture fixation in children used an extended lateral approach, with its possible complications. In the present report, we describe the operative treatment of 2 children (12 and 13 years old), who had a displaced intra-articular fracture of the calcaneus, using a minimally invasive sinus tarsi approach. Adequate reduction was obtained in both cases with no soft tissue complications or implant discomfort. Fixation was obtained using 3.5-mm cortical screws. Anatomic joint alignment was restored. The children were followed up until they had both resumed their full activities with no complications. We recommend this approach for operative treatment of displaced intra-articular fractures of the calcaneus, because it addresses the intra-articular displacement, which is the most important element of the deformity in children.

Orthopedic management of children with multiple injuries.

Trauma in children is a serious problem that has a major medical, social, and financial impact on the society. More than 10,000 children die in the United States each year from serious injury ( 50% of all deaths in children). Nearly one in every six children ( 10 million children) visit the emergency department each year in the United States because of trauma. Boys are injured twice as often as girls.1–3 When children suffer a severe trauma, they usually sustain abdominal, head, and chest injuries, which can be potential life-threatening injuries. In the same time, most children with multiple injuries will sustain extremity injuries and fractures. Orthopedic injuries are rarely life threatening; however, they are commonly encountered in children with multiple injuries and can be a cause for long-term morbidity.4 The treatment of children with multiple injuries should follow the principles of the Advanced Life Trauma Support, and orthopedic care must never precede the treatment of more serious life-threatening injuries.3 It should be noted that children with multiple injuries have better survival than adults.5,6 The orthopedic injuries, despite that they are rarely fatal, can still be a reason for long-term morbidity and disability.4,5,7 Optimal orthopedic management should be provided to children with multiple injuries keeping in mind that their recovery is possible even in the most severely affected cases. Presence of skeletal injuries worsens the prognosis of the children with multiple injuries. The pediatric trauma score has a close relation to survival. It consists of six parameters. One of these elements is presence of skeletal injuries.8 According to this score, the presence of multiple fractures or open fracture carries a worse prognosis than presence of a single closed fracture. This article will focus on the musculoskeletal management of the multiple injuries in pediatric population. It will give an overview to both orthopedic and nonorthopedic trauma surgeons regarding the important facts related to the orthopedic aspects of the management of children with multiple injuries. Initial management of extremity injuries should include the following:3

Ilio-Sacral (IS) Screw Fixation for Sacral and Sacroiliac Joint (SIJ) Injuries in Children.

Background: Treatment of sacral fractures and sacroiliac joint (SIJ) disruption with percutaneous ilio-sacral (IS) screw fixation had become a more popular treatment option. There has been no study that specifically assessed IS fixation in children. The purpose of this study is present our results with fixation of the sacral fractures and SIJ disruption using IS screw in children 18 years old and younger. Methods: This is a retrospective review chart for children with sacral fracture or SIJ disruption who were treated by IS fixation in the period from 2000 to 2012. The patients were assessed for the following (age, sex, type of injury, associated injuries, surgery, complications, postoperative return of function, healing of the injury, and return to function). Results: In the studied period (2000 to 2012), 11 patients who had either sacral fracture (4 patients) or SIJ (7 patients) disruption were treated by IS screws. The average age of these patients was 14 years (range, 6 to 17 y). Six patients had 1 screw and 5 patients had 2 screws. Eight patients had their entire fixation in S1, and 3 patients had 1 screw in S1 and 1 screw in S2. All screws were cannulated and were inserted over a guidewire with fluoroscopy and/or navigation guidance. Five patients had added anterior fixation of the pelvis. One patient was lost for follow-up. All patients (except 1) achieved healing of their injuries with no displacement or implant failure with return of function. One patient had failure of fixation and needed revision. One patient had neurological complication related to screw insertion. Conclusions: IS screws can be safely used to treat sacral fractures and SIJ injuries in children. This was feasible in children as young as 6 years old. The complications of the procedure were minimal with good stability obtained by IS screws. Level of Evidence: Level IV—case series.

Hepatitis C Viral Infection as an Associated Risk Factor for Necrotizing Fasciitis

Necrotizing fasciitis is a rare soft tissue infection associated with a high mortality rate. Several risk factors for the development of necrotizing fasciitis have been studied, which has given surgeons insight into the types of patients who are more likely to present with this rapidly progressive infection. The concomitant diagnosis of hepatitis C viral infection has not been reported in the literature previously. In this retrospective study covering a 12-year period in 1 Level I trauma center, 10 (34%) of 29 patients presenting with necrotizing fasciitis had an underlying diagnosis of hepatitis C viral infection. The mortality rate in patients with hepatitis C viral infection was 30% compared with 21% for those without hepatitis C viral infection (P=.59). The proportion of patients presenting with the concomitant diagnosis of hepatitis C viral infection and necrotizing fasciitis was statistically greater than that expected from the prevalence of hepatitis C viral infection in the general population (1.8%; P<.001).Our study showed that hepatitis C viral infection is a risk factor for developing necrotizing fasciitis. Although our sample size was too small to show a statistical significance, we believe that a clinically significant increase in mortality of necrotizing fasciitis occurred in patients with concomitant hepatitis C viral infection. Therefore, the presence of hepatitis C viral infection in patients presenting with symptoms of necrotizing fasciitis should raise the clinical suspicion for this diagnosis, with the potential for a worse prognosis.

Pediatric distal femur fixation by proximal humeral plate.

Distal femoral metaphyseal fractures are common injuries in children. Multiple treatment options have been described for this type of injury. For older children with distal metaphyseal fracture, there is still no optimal method of fixation. We propose that the commonly used proximal humeral plate can provide good method of fixation for this fracture in adolescents. Two children (12 and 14 years old) with distal metaphyseal femoral fracture were treated with proximal humeral plate. We describe the surgical technique and postoperative management. The two children healed with good alignment and full range of motion of the knee. No external immobilization (other than knee immobilizer for the first 2 weeks) was used. We concluded that proximal humeral plate can provide adequate fixation for teenagers with distal femoral metaphyseal fracture. It is readily available; provide multiple options for screw fixation in the distal part of the fracture and fits easily on the distal part of the femur proximal to the physis.