Ralph Walter Christian

Tertiary survey in trauma patients: avoiding neglected injuries

INTRODUCTION Medical personnel in trauma centres in several countries have realised that undiagnosed injuries are common and are now focussing their attention on reducing the incidence of these injuries. Tertiary survey is a simple and easy approach to address the issue of undiagnosed injuries in trauma patients. Tertiary survey consists of reevaluating patients 24 hours after admission by means of an anamnesis protocol, physical examination, review of complementary tests and request for new tests when necessary. OBJECTIVE To show the importance of tertiary survey in trauma patients for diagnosing injuries undetected at the time of initial survey. METHODS A standardised protocol was used to perform a prospective observational study with patients admitted through the emergency department, Department of Orthopaedics and Trauma, Santa Casa de São Paulo. The patients were reevaluated 24 hours after admission or after recovering consciousness. New physical examinations were performed, tests performed on admission were reassessed and new tests were requested, when necessary. RESULTS Between February 2012 and February 2013, 526 patients were evaluated, 81 (15.4%) were polytraumatised, and 445 (84.6%) had low-energy trauma. A total of 57 new injuries were diagnosed in 40 patients, 61.4% of which affected the lower limb. Diagnosis of 11 new injuries (19.3%) resulted in changes in procedure. CONCLUSION The application of the protocol for tertiary survey proved to be easy, inexpensive and beneficial to patients (particularly polytraumatised patients) because it enabled identification of important injuries that were not detected on admission in a large group of patients.

Tertiary assessment of trauma patients in a hospital in the city of São Paulo: a question of necessity

Objective To minimize the occurrence of missed injuries, the tertiary evaluation was introduced consisting of reassessment of the patient, 24 hours after admission, with: complete history, physical examination, review of exams and diagnostic testing if necessary. Methods Observational study evaluating trauma patients admitted to a teaching hospital in São Paulo, according to a protocol for tertiary evaluation. Results Between February and May 2012, for 12 weeks, 182 patients were submitted to tertiary evaluation, 100 (55%) polytraumatized and 82 (45%) were victims of low-energy trauma. Neglected lesions were observed in 21 (11.5%) patients, who had 28 missed injuries. Of these 28 lesions, seven (25%) required surgical treatment. Conclusion Strategies including formal tertiary evaluation, the protocol applied for assessing trauma victims, seem to be beneficial in these patients, regardless of the mechanism of trauma. The method is easily applied, effective and has low cost in identifying missed injuries in the victims of trauma.

Resistência mecânica às forças de tração e flexão: proposta de novo desenho para os pinos de Schanz dos fixadores externos monolaterais

OBJECTIVE: To determine the mechanical resistance to traction and flexion of three models of Schanz pins, two of them available in Brazil, and the one proposed in this study: a conic pin with 5.0 mm diameter, 40 mm thread length, 3.2 mm bore, and the one proposed in this paper, with 5.0 mm in diameter, 3.2 mm bore, and 15 mm thread length, in order to show which one is the most effective. METHODS: The authors built 48 test samples divided in six groups, with eight sample per group. Traction strength was tested in groups 1, 2, and 3 using a traction machine manufactured by ITM®. To check flexion strength in groups 4, 5, and 6, they used a bench perforator manufactured by Cardoso® FFC-20 in the pin installation, and then the Universal Assay Machine ZD100PU. RESULTS: In traction tests, the conic pins stood a mean traction of 98.462 kgf, those with uniform long thread (40 mm) 283.70 kgf, and the proposed pins with uniform thread of 15 mm, stood the mean strength of 116.947 kgf. The statistic difference among the groups was not significant. In the flexion test, the conic pins stood a strength of 6.563 kgf, the pins with uniform thread of 40 mm stood the mean strength of 6.177 kgf, and the proposed pins stood the mean strength of 30.275 kgf, there being a significant difference when compared to the previous groups. CONCLUSIONS: The three models of Schanz pins presented equivalent traction strength, and the proposed model - thread length of 15 mm - is significant more resistant to flexion strengths.

Biomechanical study: resistance comparison of posterior antiglide plate and lateral plate on synthetic bone models simulating Danis-Weber B malleolar fractures

Objective The purpose of this study was to compare different positions of plates in lateral malleolar Danis-Weber B fractures on synthetic bone: a lateral plate and a posterior antiglide plate. Methods Short oblique fractures of distal fibula at the level of the syndesmosys were simulated with a fibular osteotomy in sixteen synthetic fibula bones (Synbone®). Eight fractures were fixed with lateral plating associated with an independent lag screw, and the other eight were fixed with posterior antiglide plating with a lag screw through the plate. A strain gage was installed at the center of each plate at the osteotomy site. Supination and external rotation forces were applied to each of the two groups at the bend. Results The lateral position plate group suffered more deformity in response to supination forces compared to the group with the posterior antiglide plate, but this result was not statistically significant. In the tests with external rotation forces, the posterior antiglide plating group had significantly higher resistance (p < 0.05). Conclusion When subjected to external rotation forces, osteosynthesis with posterior antiglide plate models simulating type B fractures of the lateral malleolus of the ankle is more resistant than that of the neutralization plate.

Resultados do tratamento das fraturas da diáfise do fêmur ipsilaterais às do colo ou transtrocantérica

Objective: To perform a radiographic and functional evaluation of the complications of diaphyseal fractures of the femur associated with ipsilateral fractures of the trochanter or the neck of the femur. Methods: From 2002 to 2007, seventeen patients were treated, of which 88% were men, with a mean age of thirty-one years and three months. Ten (59%) had associated fractures of the femoral neck and seven (41%) had associated trochanteric fractures. The final range of motion of the hip and knee, the radiographic fracture consolidation, and the type of implant, used were evaluated, both at the time and retrospectively, based on the patients’ records. The mean follow-up time was 48 months. Results: All the trochanteric fractures consolidated without residual deformities. Of the femoral neck fractures, three (30%) presented delayed consolidation and two consolidated with in varus deformity. Two patients had delayed diaphyseal consolidation. All the associated diaphyseal/trochanteric fractures had good or excellent functional outcomes. Of the associated neck fractures, seven (70%) had excellent or good results, two had regular results, and one had a bad result. Conclusions: The association of diaphyseal with trochanteric femur fractures showed better radiographic and functional results, with less complications, than the association of diaphyseal and femoral neck fractures.

Fat embolism syndrome in femoral shaft fractures: does the initial treatment make a difference?

Objective To identify the risk factors correlated with the initial treatment performed. Methods This is a retrospective study involving a total of 272 patients diagnosed with femoral shaft fractures. Of the patients, 14% were kept at rest until the surgical treatment, 52% underwent external fixation, 10% received immediate definitive treatment, and 23% remained in skeletal traction (23%) until definitive treatment. Results There were six cases of fat embolism syndrome (FES), which showed that polytrauma is the main risk factor for its development and that initial therapy was not important. Conclusion Polytrauma patients have a greater chance of developing FES and there was no influence from the initial treatment.

Late postoperative analysis of the tip-apex distance (TAD) in pertrochanteric fractures: is there an accommodation of the implant within the bone?

INTRODUCTION This study measured the tip-apex distance (TAD) values in the immediate postoperative period and following weight-bearing and fracture impaction in patients undergoing osteosynthesis with dynamic hip screw and cephalomedullary nail. OBJECTIVE To correlate the Baumgaertner index in the immediate postoperative period with values obtained after impaction of the fracture with the accommodation of the cephalic implant in the femoral head. PATIENTS AND METHODS Radiographic TAD measurements were taken with AGFA-VIEW® of 82 patients with a mean age of 72 years with pertrochanteric fractures who were operated on and the fracture fixed with DHS- Synthes®, TFN-Synthes®, or Gamma Nail III-Stryker® in the immediate postoperative period, and following weight-bearing and fracture impaction (mean 3-8 weeks after surgery). RESULTS The overall average TAD decreased from 20.3mm to 18.2mm. Regardless of the instability of the fracture, the age of the patient or the implant used, TAD decreased between the immediate postoperative period and following fracture impaction. CONCLUSION The osteosynthesis of pertrochanteric fractures was associated with important accommodation of the cephalic implant in the femoral head with decreased TAD values after weight-bearing.

Tibial shaft fracture and ankle injury - Case report

The authors report on a case of tibial shaft fracture associated with ankle injury. The clinical, radiological and surgical characteristics are discussed. Assessment of associated injuries is often overlooked and these injuries are hard to diagnose. When torque occurs in the lower limb, the ankle becomes susceptible to simultaneous injury. It is essential to make careful assessment based on clinical, radiographic, intraoperative and postoperative characteristics in order to attain functional recovery.

Postoperative infection in patients undergoing inspection of orthopedic damage due to external fixation

Objective To conduct a retrospective analysis on cases undergoing inspection of orthopedic damage, at an orthopedic emergency service in a teaching hospital, with the aim of evaluating patients with postoperative infection after conversion to internal osteosynthesis. Methods This was a retrospective analysis covering the period from June 2012 to June 2013, on patients who underwent inspection of orthopedic damage due to external fixation and subsequently were converted to definitive osteosynthesis using a nail or plate. Results We found an infection rate of 13.3% in our sample and, furthermore, found that there had been technical errors in setting up the fixator in 60.4% of the cases. Conclusion We found an infection rate that we considered high, along with inadequacies in constructing the external fixator. We emphasize that this procedure is not risk-free and that training for physicians who perform this procedure should be mandatory.

Como o especialista em ortopedia e traumatologia avalia o atendimento ao trauma ortopédico no Brasil

Declaramos inexistencia de conflito de interesses neste artigo 1 – Instituto de Ortopedia e Traumatologia da Faculdade de Medicina – USP 2 – Servico de Ortopedia da Faculdade de Medicina de Ribeirao Preto – USP 3 – Hospital do Trabalhador – Universidade Federal do Parana 4 – Instituto Nacional de Traumatologia e Ortopedia – RJ 5 – Hospital Ipanema – Rio de Janeiro 6 – Departamento de Ortopedia da Escola Paulista de Medicina UNIFESP 7 – Servico de Ortopedia da Santa Casa de Sao PauloOBJECTIVES: The aim of this article is to present the data collected by Datafolha institute, from September 23rd. through October 18th. 2010 about orthopedic trauma care in Brazil. METHOD: A quantitative analysis based on telephonic interviews has been performed. From Brazilian Orthopedic Society database containing more than 7000 records. A structured query has been applied and the interview lasted around 25 minutes. RESULTS: 97% of interviewees dedicate part of his/her time to orthopedic trauma. 87% of all interviewees dedicate his/her time to more than one sub-specialty. The majority of orthopedic trauma patients comes from government insurance system (43%), while 41% of patients come from private insurance. 61% of all interviewees think that the quality of public health system could be rated as unsatisfactory. Northeast of Brazil is the place where the majority of patients are from public health system and where we have highest rates of dissatisfaction (85%) related to available infrastructure for orthopedic trauma care. Half of all interviewed individuals have problems for getting private insurance authorization previously to a surgery. CONCLUSIONS: Orthopedic trauma is a specialty practiced by the vast majority of orthopedic surgeons in our country. Neither the infrastructure nor the salaries satisfy the majority or orthopedic surgeons dedicated to trauma care.