Richard H. Lange

Open tibial fractures with associated vascular injuries: prognosis for limb salvage.

Open tibial fractures complicated by limb-threatening vascular injuries present an infrequent but difficult management problem. Twenty-three cases were reviewed with an ultimate amputation rate of 61% (22% primary, 39% delayed). Crush injuries, segmental tibial fractures, and revascularization delays of greater than 6 hours were associated with a bad outcome. Guidelines for primary amputation (crushing injuries, delay in revascularization, segmental tibial fractures) are proposed and implications of limb salvage are reviewed.

Pelvic ring disruptions with symphysis pubis diastasis. Indications, technique, and limitations of anterior internal fixation.

The management of disruption of the pelvic ring is both complex and controversial. Twenty-four injuries associated with symphysis pubis diastasis were reviewed to evaluate a two-hole plate technique of anterior internal fixation as compared to four-hole plate anterior fixation. The two-hole plate technique appears to be quite acceptable for maintaining reduction of the diastasis and therefore can be used to manage most anteroposterior compression injuries (those without complete posterior disruption). Vertical shear injuries, all of which are grossly unstable, can also be managed with anterior two-hole plates. However, this fixation method must be supplemented with some form of posterior stabilization to maintain pelvic ring reduction.

Results in patients with craniocerebral trauma and an operatively managed acetabular fracture

Summary: Results in 23 patients with significant craniocerebral trauma (Glasgow Coma Scale ≤10) and displaced acetabular fracture requiring surgery were reviewed after a minimum follow-up of 1 year. Despite a postoperative anatomic reduction in all but one case, clinical outcome for these hips was poor, with an average Harris hip rating of 59. Patients older than 40 years had a significantly poorer outcome than did younger patients (p = 0.004). Postoperative problems occurred in 70% of patients (n = 16); the largest portion of these represented symptomatic heterotopic bone, which occurred in 61%. None of the four patients who had an anterior ilioinguinal surgical approach had symptomatic heterotopic ossification. The average Glasgow outcome score was 3.9 out of 5, and 20 of the 23 patients, despite a prolonged convalescence, were able to return to independence and self-care. The authors conclude that patients with combined significant craniocerebral trauma and an operatively managed displaced acetabular fracture are likely to have compromised hip function despite a well-executed osteosynthesis. This was especially true for those patients over age 40 in this series. The authors suggest that if the fracture pattern permits it, the operative management of the acetabular fracture in these patients be by an anterior ilioinguinal approach, so as to minimize the formation of heterotopic bone.

Biomechanical and Histological Evaluation of the Herbert Screw

The Herbert screw has been demonstrated to have widespread clinical applicability. A biomechanical and histological evaluation of the Herbert screw was conducted to better define its applications. When subjected to pull-out, toggle, and compression testing, in a cancellous bone calf model, it was demonstrated to be biomechanically inferior to the 4.0 mm ASIF cancellous screw. The use of two Herbert screws minimized but did not eliminate this difference. Articular cartilage healing in a rabbit model was consistently demonstrated if the Herbert screw was buried deep to the osteochondral junction. However, toluidine blue histochemical staining showed that the hyaline-like repair cartilage differed qualitatively from normal cartilage. Utilization of the Herbert screw should include an understanding of the limitations of its fixation potential and a recognition of the repair response after intraarticular applications.

Biomechanical analysis of mallet finger fracture fixation techniques

A biomechanical study was conducted to determine the best fixation technique for mallet finger fracture among four commonly used methods. Considerations were technical complications, biomechanical properties, and maintenance of reduction. Techniques tested included Kirshner wire, figure-of-eight wire, tension band wire, and tension band suture. Technical complications were frequent with both the Kirschner wire and tension band wire techniques. Biomechanical testing yielded significantly greater energy absorbed to failure and a trend toward greater peak loads to failure for both the figure-of-eight wire and tension band suture techniques. Irreversible loss of reduction during testing occurred in all of the Kirschner wire-fixed fractures, in 60% of the tension band wire-fixed fractures, and in 50% of the figure-of-eight wire-fixed fractures. No irreversible failure occurred in the tension band suture group.

Results of knee manipulations after anterior cruciate ligament reconstructions

We analyzed the results of knee manipulations in 42 knees that had persistent flexion or extension deficits after intraarticular ACL reconstructions. All manipula tions were done under a spinal or general anesthetic and, in 10 cases, arthroscopic debridement of adhe sions also was performed. The average time from re construction to manipulation was 7 months (range, 3 to 14 months) and the average followup was 26 months (range, 6 to 56 months). At manipulation, average flex ion was increased from 95° to 136° and average ex tension from 11° to 3°. In no case was motion gained at the expense of joint stability and, at final followup, average flexion and extension were 127° and 4°, re spectively. The final range of motion achieved was not affected by the time to manipulation, severity of pre manipulation flexion deficit, or concomitant arthro scopic debridement of adhesions. However, knees with premanipulation extension deficits of ≥15° achieved significantly less final extension than knees with lesser premanipulation deficits. Overall, manipulations were a safe and effective method for improving both flexion and extension in 86% of the knees that had restricted motion after ACL reconstructions.

RISK FACTORS FOR RESTRICTED MOTION AFTER ANTERIOR CRUCIATE RECONSTRUCTION

A retrospective review of 373 patients who had undergone anterior cruciate ligament (ACL) reconstruction utilizing the central third of the patellar tendon was undertaken to identify those factors that placed a patient at risk for restricted postoperative motion (flexion < or = 125 degrees or flexion contracture > or = 10 degrees). Stepwise logistic regression analysis determined that the variables most strongly correlated with restricted final range of motion (ROM) were open surgery (P = .0008) and reconstruction performed < or = 7 days after the initial injury (P = .004). Age, associated meniscal repair, or associated collateral ligament injuries did not significantly affect the ROM. A subgroup of 204 patients arthroscopically reconstructed more than 7 days post-injury were significantly less likely to have limited motion when ROM exercises were begun within 2 days of surgery (P = .008). These data support delayed, arthroscopic ACL reconstruction followed by early ROM exercises as useful techniques for avoiding postoperative motion problems.

Traumatic lateral scapular displacement: an expanded spectrum of associated neurovascular injury.

Summary: The clinical entity of “scapulothoracic dissociation” has been reported as an uncommon but devastating shoulder girdle disruption. All previously identified closed injuries have been associated with arterial and brachial plexus compromise; therefore, neurovascular disruption has been presented as an essential diagnostic clinical finding of scapulothoracic dissociation. We have identified and managed four patients who satisfy all the radiographic criteria for scapulothoracic dissociation but who have presented with a spectrum of neurovascular conditions ranging from entirely normal to complete disruption. These patients illustrate a previously unrecognized, or at least unreported, continuum of potential neurovascular compromise associated with disruption of the scapulothoracic articulation. An expanded and more descriptive classification scheme for “traumatic lateral scapular displacement” is proposed to emphasize the spectrum of possible presentations of this injury.

Lower-extremity compartment syndromes associated with use of pneumatic antishock garments

Pneumatic antishock garments (PASG) are frequently used to initially support and manage traumatic hypovolemic shock. PASG have been implicated in the development of complicating compartment syndromes of the lower extremities, but cause and effect have not been clearly defined. The present report documents the occurrence of bilateral compartment syndromes in uninjured lower extremities after using PASG and reviews similar reported cases.

Skeletal management of humeral shaft fractures associated with forearm fractures.

Nine cases of ipsilateral humeral shaft and forearm fractures in multiply injured patients were reviewed in an attempt to ascertain the preferred management of these complex injuries. Satisfactory anatomic and functional results were achieved only in those cases treated by rigid internal fixation of the humeral fractures. Nonoperative management is associated with a significant risk of malunion or nonunion of the humerus.