Robert A. Winquist

Diagnosis and Management of Compartmental Syndromes

Patients at risk for compartmental syndromes challenge both the diagnostic and the therapeutic abilities of the physician. Suboptimum results may be due to delays in diagnosis and treatment, to incomplete surgical decompression, and to difficulties in the management of the limb after decompression. Although careful clinical assessment permits the diagnosis of a compartmental syndrome in most patients, we have found measurement of tissue pressure and direct nerve stimulation to be helpful for resolving ambiguous or equivocal cases. In our experience, the four-compartment parafibular approach to the leg and the ulnar approach to the volar compartments of the forearm provide efficient and complete decompression of potentially involved compartments. The skeletal stabilization of fractures associated with compartmental syndromes may facilitate management of the limb after surgical decompression.

Fractures of the proximal part of the femur.

The orthopaedic surgeon has a multitude of internal fixation devices and techniques available for use in the treatment of subtrochanteric fractures of the proximal femur. The successful use of second-generation locking nails is technically demanding. Close attention to positioning of the patient, reduction of the fracture, placement of the guide-wire, and insertion of the nail and of the proximal and distal locking screws is mandatory. The newer, high-strength hip-screws allow good fixation of a fracture that extends into the piriformis fossa. If medial comminution is present, this technique is best performed in conjunction with indirect reduction and bone-grafting. With proper technique, these devices allow the surgeon to manage predictably a complex subtrochanteric fracture that previously had to be treated with traction or extensive dissection and with (frequently inadequate) internal fixation.

Fractures of the femoral neck in patients between the ages of twelve and forty-nine years.

Femoral neck fractures in young adults have a poor prognosis because the incidence of non-union and aseptic necrosis is high. We reviewed the results in twenty-seven consecutive patients with a femoral neck fracture who were younger than fifty years and who were treated with a standard protocol at Harborview Medical Center from 1975 to 1981. There were twenty-two male and five female patients, and they ranged in age from twelve to forty-nine years (mean, 32.4 years). Twenty patients were involved in high-velocity trauma and twelve of them had significant injuries to other organ systems. One of the remaining seven patients had sustained the fracture while running, and in the other six the fracture was associated with a metabolic disorder. Eight patients had a Garden Stage-II fracture; twelve, Stage-III; and seven, Stage-IV. The fractures were fixed with multiple 6.5-millimeter cancellous screws after adequate closed reduction, which was usually performed within eight hours after injury. All of the fractures united and there were no wound infections. Aseptic necrosis of the femoral head developed in five patients (20 per cent), three of whom had symptoms at the time of writing and will require surgical revision of the hip.

Intramedullary Nailing of Distal Metaphyseal Tibial Fractures

BACKGROUND The treatment of distal metaphyseal tibial fractures remains controversial. This study was performed to evaluate the results of intramedullary nailing of distal tibial fractures located within 5 cm of the ankle joint. METHODS Over a sixteen-month period at two institutions, thirty-six tibial fractures that involved the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. Ten fractures with articular extension were treated with supplementary screw fixation prior to the intramedullary nailing. Radiographs were reviewed to determine the immediate and final alignments and fracture-healing. The Short Form-36 (SF-36) and Musculoskeletal Function Assessment (MFA) questionnaires were used to evaluate functional outcome. RESULTS Acceptable radiographic alignment, defined as <5 degrees of angulation in any plane, was obtained in thirty-three patients (92%). No patient had any change in alignment between the immediate postoperative and the final radiographic evaluation. Complications included one deep infection and one iatrogenic fracture at the time of the intramedullary nailing. Six patients could not be followed. The remaining thirty fractures united at an average of 23.5 weeks. Three patients with associated traumatic bone loss underwent a staged autograft procedure, and they had fracture-healing at an average of 44.3 weeks. The functional outcome was determined at a minimum of one year for nineteen patients and at a minimum of two years (average, 4.5 years) for fifteen patients. At one year, there were significant limitations in several domains despite fracture union and maintenance of alignment, but there was improvement in the MFA scores with time. CONCLUSIONS Intramedullary nailing is an effective alternative for the treatment of distal metaphyseal tibial fractures. Simple articular extension of the fracture is not a contraindication to intramedullary fixation. Functional outcomes improve with time.

Femoral shaft fractures in adolescents: a comparison between traction plus cast treatment and closed intramedullary nailing.

Summary: Two groups of adolescents with femoral shaft fractures treated by two different methods (traction plus cast and closed intramedullary nailing) at two different hospitals were studied retrospectively. Two of 13 fractures in the nonsurgically treated group had significant shortening requiring corrective surgery. None of the 13 fractures in the surgically treated group had significant complications. Guidelines for treatment of these fractures are proposed.

Displaced hip fractures in children and adolescents.

The results of ten acute, displaced proximal femoral fractures in patients 14 years and under are reported. These high-risk fractures were managed with urgent open reduction and pin or screw fixation with supplemental spica casting. The exception to this protocol was in two Delbets type IV (intertrochanteric) fractures which were managed by closed reduction and spica casting. There was a case of partial avascular necrosis of the femoral head in a type I transepiphyseal fracture. At a minimum followup of 2 years the patients were asymptomatic with no significant limitation of hip motion.

Subtrochanteric fracture of the femur. Fixation using the Zickel nail.

We divided 131 patients who had a subtrochanteric fracture into four clinical groups: elderly patients who had a fracture secondary to minor trauma, patients who had a fracture due to high-energy trauma, those who had a pathological fracture, and patients who had a fracture that previously had been treated unsuccessfully with internal fixation. In each patient operative fixation was performed using the Zickel device, and overall satisfactory results were obtained in 90 per cent. Considering the challenging nature of subtrochanteric fractures, complications, which included a rate of non-union of approximately 5 per cent, were minimum. Technical details for each of the four groups are emphasized.

Closed intramedullary osteotomies of the femur.

Closed intramedullary osteotomies offer a safe way to correct many femoral deformities. It is the safest method for correcting leg length inequality in adults, having a low infection rate and low complication rate. Unfortunately, the procedure is technically demanding, requiring great attention by two surgeons. The derotational osteotomy is not nearly as complex; it is a relatively simple procedure for a surgeon experienced in closed intramedullary nailing. Correction is adequate with goniometer measurement, but an interlocking nail is necessary to maintain position. Correction of angulatory deformities is more difficult and requires careful study of anteroposterior, lateral, and oblique radiographs to be certain that the procedure is technically possible. Intramedullary bone grafting is frequently necessary for an open wedge. Distal osteotomies are encumbered by nonunion problems.

Nonunion of the tibia treated with Küntscher intramedullary nailing.

Nonunion of the tibia was treated by Küntscher intramedullary nailing un 48 patients. Thirty patients were treated with a completely closed intramedullary nailing and 18 required an open tibial osteotomy to realign the fracture. Bone grafting was not performed. The average time elapsed from injury to surgery was 15 months and the average healing time, as determined roentgenographically, was nine months following surgery. Three postoperative infections cleared with debridement and antibiotic therapy and subsequently united. There were two failures with persistent nonunion. Closed intramedullary nailing is an effective method of managing nonunion of the tibia in properly selected cases.

Closed intramedullary shortening of the femur.

Closed intramedullary shortening of the femur in the adult provides a method for leg length equalization that poses minimal operative risks, maximizes healing, and produces an excellent functional and cosmetic result. The etiology of anisomelia and any associated abnormalities must be carefully analyzed preoperatively. A series of 40 closed intramedullary shortenings of the femur were performed; shortening averaged 3.3 cm (range 2.0 to 5.0 cm). Three patients had significant complications: delayed union in one patient required renailing; two cases of symptomatic external rotation deformity required correction. The technique for the procedure is demanding in terms of experience and equipment. Otherwise, intramedullary femoral shortening is an excellent method for managing adult anisomelia.