Fred F. Behrens

Morbidity and mortality in elderly trauma patients

BACKGROUND Despite an increasing incidence, relatively few studies have examined the factors that predict morbidity and mortality in older patients and several reports have found standard predictors such as the Injury Severity Score to be less useful in this patient population. Similarly, the effect of skeletal injury has not been examined with regard to complications and mortality. The purpose of this study was to review a large multicenter experience with elderly trauma patients to isolate factors that might predict morbidity and mortality. The potential effect of skeletal long-bone injury was of particular interest. METHODS The charts of all patients older than 60 years who were admitted to one of four Level I trauma centers after sustaining blunt trauma were reviewed. Mechanisms of injury included in the study were motor vehicle crash, pedestrian struck, fall from a height, and crush injury. Slip-and-fall injuries were excluded. A total of 326 patients met inclusion criteria. Variables studied included age, sex, mechanism of injury, Injury Severity Score (ISS), Revised Trauma Score, Glasgow Coma Scale (GCS) score, blood transfusion, fluid resuscitation, surgery performed (laparotomy, long-bone fracture stabilization, both), and timing of surgery. Outcome variables measured included incidence of adult respiratory distress syndrome, pneumonia, sepsis, myocardial infarction, deep venous thromboembolism, gastrointestinal complications, and death. chi2, logistic regression, t test, and nonparametric analyses were done as appropriate for the type of variable. RESULTS The average age of the patients was 72.2+/-8 years. Overall, 59 patients (18.1%) died, of whom 52 of 59 survived at least 24 hours. Statistical significance for continuous variables (p < 0.05) using univariate analysis was reached for the following factors for the patients who died: higher ISS (33.1 vs. 16.4), lower GCS score (11.5 vs. 13.9), greater transfusion requirement (10.9 vs. 2.9 U), and more fluid infused (12.4 vs. 4.9 L). Logistic regression analysis was performed to determine the factors that predicted mortality. They included (odds ratios and p values in parentheses) transfusion (1.11, p = 0.01), ISS (1.04, p = 0.008), GCS score (0.87, p = 0.007), and fluid requirement (1.06, p = 0.06). Regarding surgery, orthopedic surgery alone had an odds ratio of 0.53, indicating that orthopedic patients was less likely to die than patients who did not undergo any surgery. Patients who underwent only a general surgical procedure were 2.5 times more likely to die (p = 0.03) and patients who underwent both general and orthopedic procedures were 1.5 times more likely to die (p = 0.32) than patients who did not require surgery. Early (< or =24 hours) versus late (>24 hours) surgery for bony stabilization did not have a statistical effect on mortality (11% early vs. 18% late). Two patients in need of bony stabilization, however, died before these procedures were performed. With regard to complications, regression analysis revealed that ISS predicted adult respiratory distress syndrome, pneumonia, sepsis, and gastrointestinal complications; fluid transfusion predicted myocardial infusion; and need for surgery and transfusion requirements predicted sepsis. These complications, in turn, were significant risk factors for mortality. This large series of elderly patients demonstrates that mortality correlates closely with ISS and is influenced by blood and fluid requirements and by GCS score. The institution-specific mortality was the same when adjusted for ISS. The need for orthopedic surgery and the timing of the surgery was not a risk factor for systemic complications or mortality in this series. CONCLUSION Mortality is predicted by ISS and by complications in older patients. Seventy-seven percent of the orthopedic injuries were stabilized early, but the timing of surgery did not have any statistical effect on the incidence of complications or mortality. (ABSTRACT TRUNCA

COMPLICATIONS OF ANKLE FRACTURES IN DIABETIC PATIENTS

Ankle fracture in patients with DM mandates a stepwise protocol to minimize the potential complications of delayed fracture healing, wound complications, and development of Charcot arthropathy. For nondisplaced ankle fracture, a nonoperative approach with increased duration of immobilization seems successful based on experience of the limited series. A displaced ankle fracture in a patient with DM requires a surgical intervention. The authors advocate tight glucose control in both groups to improve the fracture milieu and to ameliorate the potential complications. Appropriate stable fixation with adequate length of immobilization is crucial for successful fracture resolution.

The effect of sacral fracture malreduction on the safe placement of iliosacral screws.

Objectives To determine the effects of cranial displacement on the safe placement of iliosacral screws for zone II sacral fractures. Design Computer imaging and dimensional analysis of a human cadaveric sacral fracture model. Setting Cadaveric dissection, Orthopaedic Research Laboratories, Newark, New Jersey. Main Outcome Measurements Six cadaveric pelves with simulated zone II sacral fractures were imaged with computed tomography at controlled cranial displacements of 5, 10, 15, and 20 mm. The area of contact at the fracture site and volume of bone available for iliosacral screw placement was graphically measured using both two- and three-dimensional computer modeling. Areas of contact were also represented in terms of the maximal number of 7.0-mm screws that could be simultaneously implanted. Results Cross-sectional contact area was decreased by 30%, 56%, 81%, and 90% at 5, 10, 15 and 20 mm of displacement, respectively. Volume of bone was decreased by 21%, 25%, 26%, and 34% for 5, 10, 15 and 20 mm of displacement, respectively. In 50% of the specimens at 15 mm and 66% of the specimens with 20 mm displacement, two iliosacral screws could not be contained simultaneously within bone. In 17% of the specimens displaced 15 mm and 50% of the specimens displaced 20 mm, the cross-sectional area was insufficient to contain a single iliosacral screw. Conclusions Although previous authors have accepted up to 15 mm of cranial displacement, the data demonstrate substantial compromise of available screw space with displacements greater than 1 cm. Fracture reduction is mandatory, as screw placement with residual displacement of 10 mm or more can endanger adjacent neural and vascular structures.

General theory and principles of external fixation.

Starting with a review of the capabilities and main complications of external fixators, this paper shows how advances made during the past two decades have rendered the method safe, reliable, and predictable. Improved component designs, new techniques of pin care, the discovery of three basic concepts that govern the safe and effective application of pin and ring fixators, and the recognition that preoperative and long-term planning are crucial to the success of the method have made external fixation the most adaptable, versatile, and gentle method for stabilizing complex injuries of soft tissue and bone.

Percutaneous methods of tibial plateau fixation.

Various methods of percutaneous fixation of tibial plateau fractures are available. The optimal method of fixation is dictated by soft tissue injury, fracture characteristics, and functional demands of the patient. Unicondylar fractures are amenable to percutaneous stabilization with screws or plates although some fractures are best approached with open techniques. Hybrid and ring external fixators are most appropriate for patients with bicondylar injuries who have severe soft tissue trauma. Use of intramedullary nails to align ipsilateral shaft fractures adjacent to percutaneously fixed plateau injuries remains controversial but may be indicated for some patients with bicondylar lesions and combined plateau and shaft fractures.

Computed radiographic measurement of limb-length discrepancy. Full-length standing anteroposterior radiograph compared with scanogram.

BACKGROUND Although a scanogram is commonly used to measure limb-length discrepancy, there are several potential pitfalls associated with this imaging technique. The purpose of the present study was to evaluate the results obtained with use of a full-length standing anteroposterior radiograph of the lower extremities and to compare them with those obtained with use of a scanogram. Both imaging studies were performed using computed radiography. METHODS One hundred and eleven patients with limb-length discrepancy had a full-length standing anteroposterior radiograph and a scanogram made on the same day. The patients included seventy-nine children and thirty-two adults in whom the discrepancy was secondary to trauma (55%), congenital shortening (18%), Blount disease (14%), or another cause (13%). Limb length and limb-length discrepancy were measured utilizing both imaging studies. The agreement between the standing anteroposterior radiograph and the scanogram was assessed with use of the correlation coefficient r, and the limits of agreement between the two imaging studies were assessed. RESULTS An average magnification of 4.6% (3.3 cm) was observed in association with the measurement of lower extremity length with use of the full-length standing anteroposterior radiograph. The mean difference in limb-length-discrepancy measurements between the two techniques was 0.5 cm, and the limits of agreement (that is, the mean plus or minus two standard deviations) were 0.5 to 1.5 cm. When the limb-length discrepancy on the standing anteroposterior radiograph was compared with that on the scanogram, the correlation coefficient r was 0.96. A difference of >0.5 cm between the limb-length discrepancy measured on the standing radiograph and that measured on the scanogram was associated with a mechanical axis deviation of >2 cm. Remaining variables, including age, gender, etiology, and scanogram ruler inclination, did not correlate with a difference in the measurement of limb-length discrepancy with use of these two imaging studies. CONCLUSIONS The measurement of limb-length discrepancy on a standing anteroposterior radiograph was very similar to that on a scanogram, especially in the absence of substantial mechanical axis deviation. These findings support the use of a standing anteroposterior radiograph of the lower extremities as the initial imaging study for patients presenting with unequal limb lengths. This approach allows for a more comprehensive radiographic evaluation of the lower extremity, including deformity analysis, while reducing the expense and radiation exposure as compared with the use of additional imaging studies for the assessment of limb-length discrepancy.

Nonarticular proximal tibia fractures: treatment options and decision making.

&NA; Nonarticular proximal‐third fractures account for 5% to 11% of tibial shaft injuries and occur as a result of a variety of mechanisms. Treatment is more challenging than for more distal fractures, and the rates of compartment syndrome and arterial injury are higher, especially for displaced fractures. Closed management often leads to varus malunion, especially when the fibula is intact. Closed treatment should therefore be reserved for nondisplaced or minimally displaced fractures with little soft‐tissue injury. Plating of the proximal tibia has become a less popular alternative because of the high incidence of infection and fixation failure. However, judicious use of lateral plates as an adjunct to medial external fixation in comminuted fractures can be effective. External fixation remains the most versatile method. It is indicated for fractures with short proximal fragments and in cases of extensive soft‐tissue injury that would preclude use of other surgical techniques. Temporary jointspanning external fixation has a role in the initial management of certain fracture patterns, particularly when accompanied by severe soft‐tissue injury. Although intramedullary nailing can lead to valgus malunion in a sizable percentage of patients with this injury, it can be useful for stabilizing fractures with proximal fragments longer than 5 to 6 cm. Placing the entry portal more proximal and lateral, locking in extension, and using specific techniques, such as blocking screws, can improve alignment after nailing. Use of an algorithm that takes into account the severity of soft‐tissue injury, the length of the fracture fragment, and the degree of fracture stability allows effective decision making among current treatment techniques.

Unilateral external fixation. Methods to increase and reduce frame stiffness.

Unilateral configurations with stiffness characteristics similar to those of the most rigid one- and two-plane bilateral constructs are easily built. Mechanically, most effective were two-plane unilateral frames with a short bone-rod distance. But single- and double-bar anterior unilateral frames had the best combination of clinical and mechanical features. To put gradual frame builddown on a rational basis, a sequence of stepwise frame reduction was developed. This sequence leads from the most rigid unilateral constructs to frames that allow almost complete force transmission across the fracture site while still providing adequate protection against the prevailing sagittal bending moments.

Bending stiffness of unilateral and bilateral fixator frames.

The structural and geometric fixator properties that best neutralize the prevailing anteroposterior and transverse bending moments at a tibial fracture site were analyzed in anatomic specimens. Clinically and mechanically, anterior unilateral frames were most effective, particularly when applied with relatively stiff components with a maximal spread between the pins in each main bony fragment and with placement of the longitudinal rod close to the tibia.

Biomechanical comparison of flexible stainless steel and titanium nails with external fixation using a femur fracture model.

Abstract: There are several options available for surgical stabilization of pediatric femoral shaft fractures. The purpose of this study was to compare the stability afforded by Ender stainless steel nails, titanium elastic nails, and one-plane unilateral external fixators for the fixation using a synthetic adolescent midshaft femur fracture model. The anterior-posterior (sagittal plane) bending, lateral (coronal plane) bending, torsional, and axial stiffness values were calculated using 6 different fixation configurations. These included pairs of 3.5-mm-diameter Ender nails with and without distal locking, 3.5- and 4.0-mm-diameter titanium elastic nails as well as single- and double-stacked monolateral external fixators. Eight synthetic femur models, 4 each with simulated transverse and comminuted fracture patterns, were sequentially tested for stability afforded by the various fracture fixation configurations. External fixation exhibited significantly greater control of anterior-posterior angulation compared with all flexible-nailing systems. Although Ender nails were slightly superior to titanium nails in control of sagittal plane angulation, this was not statistically significant. Compared with the external fixation constructs, all 4 flexible nail constructs demonstrated higher torsional stability. For prevention of axial shortening, all fixation methods were similar for the transverse fracture pattern, whereas external fixation was superior to flexible nails in the comminuted fracture model. No significant benefit was demonstrated with double stacking of external fixators. These findings may help guide clinicians choose the optimal fixation method for treatment of pediatric femoral shaft fractures.