Thomas F. Varecka

A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft.

OBJECTIVES To determine if there are differences in healing, complications, or number of procedures required to obtain union among open and closed tibia fractures treated with intramedullary (IM) nails inserted with and without reaming. DESIGN Prospective, surgeon-randomized comparative study. SETTING Level One trauma center. PATIENTS Ninety-four consecutive patients with unstable closed and open (excluding Gustilo Grade IIIB and IIIC) fractures of the tibial shaft treated with IM nail insertion between November 1, 1994, and June 30, 1997. INTERVENTION Interlocked IM nail insertion with and without medullary canal reaming. MAIN OUTCOME MEASURES Time to union, type and incidence of complications, and number of secondary procedures performed to obtain union. RESULTS For open fractures, there were no significant differences in the time to union or number of additional procedures performed to obtain union in patients with reamed nail insertion compared with those without reamed insertion. A higher percentage of closed fractures were healed at four months after reamed nail insertion compared with unreamed insertion (p = 0.040), but there was not a difference at six and twelve months. More secondary procedures were needed to obtain union after unreamed nail insertion for the treatment of closed tibia fractures, but the difference was not statistically significant given the limited power of our study (p = 0.155). Broken screws were seen only in patients treated with smaller-diameter nails inserted without reaming, and the majority occurred in patients who were noncompliant with weight-bearing restrictions. There were no differences in rates of infection or compartment syndrome. CONCLUSION Our findings support the use of reamed insertion of IM nails for the treatment of closed tibia fractures, which led to earlier time to union without increased complications. In addition, canal reaming did not increase the risk of complications in open tibia fractures.

The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury.

The cases of forty-three patients who had a Type-IIIB open fracture of the tibial shaft were reviewed to determine the effect of treatment of the soft-tissue injury on the rate of major complications. An infection developed in two of the eleven patients who had had early muscle-flap coverage compared with ten of the nineteen who had been managed by open care of the wound and nine of the thirteen who had had later flap coverage. Patients who had had bone-grafting after complete re-epithelialization of the wound, regardless of the method of closure, had a lower rate of early infection (none of sixteen compared with four of fifteen) and an earlier average time to union (fifty-four compared with sixty-three weeks) than those in whom the wound was not completely closed or was draining at the time of bone-grafting. Delayed intramedullary nailing with reaming was associated with a high rate of infection (nine of nineteen patients), regardless of the condition of the soft tissue at the time of nailing. In our opinion, adequate débridement and early assessment of the soft-tissue defect are necessary so that appropriate soft-tissue coverage can be provided within the first one to two weeks. When the soft-tissue portion of the injury is addressed promptly and definitively and then allowed to heal completely, secondary osseous reconstruction may proceed with fewer complications.

Exchange reamed intramedullary nailing for delayed union and nonunion of the tibia

Twenty-eight tibial fractures, initially treated with nonreamed interlocking nails, were exchanged to reamed intramedullary nails to promote union. Initially, there were 8 closed fractures with compartment syndromes; 5 Type 2 open fractures; 6 Type 3 A injuries; and 6 Type 3B injuries. Exchange nailing was performed if followup radiographs did not show callus formation between 3 and 5 months after injury. Originally, 16 of the 28 nailings were statistically locked. Twenty-five of 27 fractures united after exchange nailing. In 2 patients with bone loss, additional bone grafting was required. Infection developed in 3 patients after exchange nailing (11%). Exchange nailing is a useful method to promote union of tibial fractures when slow consolidation occurs after initial treatment with a nonreamed nail. This method should be combined with autogenous bone grafting in patients with bone loss. The procedure is safe and effective in closed and minor open fractures; however, caution should be exercised in patients with prior Grade 3B open fractures because of the risk of infection.

Decision making errors in the use of interlocking tibial nails

Seventy-one fractures of the tibial shaft were treated with interlocking intramedullary nails. None of the fractures were treated with static locking of the intramedullary nails. These 71 fractures were studied to determine whether certain fracture patterns are prone to loss of alignment when static interlocking is not used. Loss of alignment was defined as shortening of 1 cm or more and/or change in angulation of at least 5°. Loss of alignment occurred in eight of the 71 (11%) fractures. Shortening and/or angulation occurred in seven of 22 spiral and short oblique fractures, and in none of 27 transverse fracture patterns. It was concluded that the dynamically locked and nonlocked modes of intramedullary nailing should not be used in the stabilization of spiral and oblique fractures of the tibial shaft.

Retrograde nailing of humeral shaft fractures: a biomechanical study of its effects on the strength of the distal humerus.

OBJECTIVES The purpose of this study was to evaluate the loss of strength in the distal humerus that resulted from the creation of two different entry portals used for retrograde humeral nailing. DESIGN Nine pairs, treated as blocks of size two, of fresh frozen humeri from individuals free of musculoskeletal disease were randomly divided into three groups in a balanced incomplete block experimental design. INTERVENTION The specimens were tested intact (control) or with an entry portal drilled in either the distal metaphyseal triangle or the proximal slope of the olecranon fossa. Two of these three conditions were applied to each pair of the bones. Therefore, three pairs of bones accommodated testing of all possible combinations of the two treatments. All specimens were tested in torsion at a rate of 30 degrees per second until failure or fracture. RESULTS The creation of an entry portal reduced the ultimate torque to 63 percent of that of the intact specimens (p = 0.044) and the energy absorbed to failure to 27 percent of that of the intact specimens (p = 0.039). The metaphyseal entry portal reduced the torque to failure to 71 percent of that of the intact specimens (p = 0.143) and the energy absorbed to failure to 37 percent of that of the intact specimens (p = 0.073), The olecranon fossa entry portal reduced the torque to failure to 55 percent of that of the intact specimens (p = 0.035) and the energy absorbed to failure to 18 percent (p = 0.058) of that of the intact specimens. CONCLUSIONS Surgeons should be aware of the loss of strength in the distal humerus after retrograde humeral nailing. This is especially important when prescribing postoperative mobilization in which the upper extremities will be used for weight-bearing in either transfers or ambulation.

RETROSTERNAL EPIPHYSEAL DISRUPTION OF MEDIAL CLAVICLE: CASE AND REVIEW IN CHILDREN

Retrosternal dislocations of the clavicle have been reported previously in adults throughout the orthopedic literature. However, in children few cases have been noted in either the pediatric, emergency, or orthopedic literature. The potential for great vessel injury as well as acute airway compromise makes the retrosternal disruption of the sternoclavicular joint a surgical emergency that must be diagnosed quickly. Diagnosis is enhanced by the cephalic tilt view and by computed tomography (CT scan), as planar x-ray and tomography do not always reveal this potentially life-threatening condition. Surgical consultation must be sought acutely; however, management may need to begin prior to definitive repair. Emergency management begins by suspecting the injury, and with immediate airway and circulatory support for the patient.

Adult trauma: getting through the night.

There has been a dramatic change in the approach to the treatment of acute musculoskeletal injuries over the past decade. The previous emphasis on so-called “early total care,” which advocated immediate definitive repair of all injuries, has shifted to an approach emphasizing “damage control orthopaedics” for a multiply injured patient. In this new paradigm, definitive repair of fractures is delayed until the patient is stabilized physiologically, associated soft-tissue injuries (if present) have healed, and optimum resources are available. However, there remain situations in which immediate treatment may be needed, such as in a patient with a pelvic ring injury and hemodynamic instability, a compartment syndrome, or an irreducible joint dislocation with associated neurovascular compromise. In these circumstances, there may not be time to safely transfer the patient to a specialized center, and emergent treatment directed at the specific problem must be provided. Emergent treatment of open fractures, compartment syndrome, and hemodynamic instability in a patient with a pelvic fracture as well as damage control in multiply injured patients should be understood by all who treat musculoskeletal injuries. Finally, a less-often discussed but no less important aspect of surgical care that may affect initial treatment decisions and outcome is sleep deprivation and fatigue of the members of the surgical team. Look for this and other related articles in Instructional Course Lectures, Volume 59, which will be published by the American Academy of Orthopaedic Surgeons in March 2010: Traditionally, the initial management of open fracture wounds was debridement within six hours after the injury to prevent infection. That guideline was based on animal experiments performed in the 1890s and …

Distal Humerus Fractures in the Elderly Population

Distal humerus fractures present complex challenges in the elderly patient. These fractures often occur in patients who are living independently but have poor bone quality and low physiologic reserve, thus complicating management decisions and treatment. The goal is a painless, functional, stable elbow that allows completion of the activities of daily living. Nonsurgical management is reserved for those who cannot tolerate surgery. Open reduction and internal fixation is the preferred choice in fractures amenable to rigid fixation and early motion. Although total elbow arthroplasty provides improved early function and similar overall outcomes in appropriately selected patients, it has the potential to cause devastating complications. With modern technology and treatment principles, as well as early definitive treatment by an experienced specialist, predictable return to function can be expected.