William G. DeLong

Initial experience with the treatment of supracondylar femoral fractures using the supracondylar intramedullary nail: a preliminary report.

Summary: Initial experience at a Level I Trauma Center with the use of a retrograde supracondylar intramedullary (IM) nail for the treatment of supracondylar and supracondylar-intercondylar intraarticular fractures of the distal femur is presented. Thirty-eight patients with 41 complex distal femur fractures were treated with this newly developed retrograde IM rod. These included 22 open fractures and 19 closed fractures. Four nonunions occurred, but all progressed to union after revision internal fixation and bone grafting. Two of five delayed unions required revision fixation. Two required screw renewal and dynamization. Thirty-five of 41 knees achieved at least 90° of knee motion. There were no infections and no problems with wound healing. Four patients developed fatigue fractures of the rod. These mechanical failures occurred when 11- and 12-mm nails were used in conjunction with 6.4-mm interlocking screws. The rod system was therefore modified to include 12- and 13-mm diameter nails and smaller 5.0-mm interlocking screws. There have been no subsequent nail failures. We are cautiously optimistic that supracondylar IM rod fixation will contribute to the management of these difficult fractures. However, further clinical trials and additional biomechanical testing should be undertaken prior to widespread use of this device

Aggressive treatment of 119 open fracture wounds.

BACKGROUND The purpose of this study was to determine whether immediate primary closure of open fracture wounds can be performed without increasing the incidence of infections and delayed unions/nonunions. Although the traditional management of these injuries has been open treatment, a trend toward immediate primary closure has evolved on our service. METHODS All open fractures presenting to an urban Level I trauma center during a 42-month period were reviewed. Of the 127 patients with open fractures, 90 patients (119 open fractures) were initially treated at the above institution within 24 hours of injury, had fractures proximal to the carpus or tarsals, and were followed-up until fracture union. All patients underwent emergent wound irrigation and debridement. The method of fracture immobilization and timing of wound closure was left to the discretion of the attending orthopedic surgeon. Immediate primary closure was used in 22 of 25 Grade I open fractures (88%), 37 of 43 Grade II fractures (86%), 24 of 32 Grade IIIa fractures (75%), 4 of 12 Grade IIIb fractures (33%), and 0 of 7 Grade IIIc fractures (0%). RESULTS Eight fractures (7%) were complicated by a deep wound infection/osteomyelitis, and 19 fractures (16%) developed a delayed union/nonunion. Statistical analysis revealed no significant difference in delayed/nonunion and infection rates between immediate and delayed closures. CONCLUSION Immediate primary closure of open fracture wounds after a thorough debridement by an experienced fracture surgeon appears to cause no significant increase in infections or delayed union/nonunions. In addition, early closure may decrease the requirement for subsequent debridements and soft-tissue procedures, thereby minimizing surgical morbidity, shortening hospital stays, and reducing costs. We feel that a randomized, prospective study of this aggressive approach to open fracture care is warranted.

Surgical management of soft tissue lesions associated with pelvic ring injury.

Mortality rates associated with pelvic ring injury combined with open wounds have decreased considerably during the past 2 decades. Consequently, increased survivability has heightened the demand for definitive stabilization techniques to address pelvic ring instability. Control of hemorrhage and avoidance of sepsis remain paramount concerns in the initial and later stages of management, respectively. Exclusion of occult and readily apparent perforations of the genital urinary and gastrointestinal tracts is essential when using a multidisciplinary approach. Recognition of open and closed degloving injury patterns and appropriate adherence to treatment guidelines will optimize outcome and avoid catastrophic complication.

Open fractures of the patella : long-term functional outcome

Seventy-nine open patella fractures in 76 patients were treated between 1986 through 1994, with an 80% incidence of multiple injuries. All were treated with irrigation and debridement, open reduction, internal fixation, and reconstruction of the extensor mechanism. In no case was a primary patellectomy performed, even with severe comminution. There were three failures of initial fixation and one asymptomatic nonunion. Average range of motion for all groups was 112 degrees, at an average follow-up of 21 months. Secondary surgical procedures were performed in 65% of knees, the majority for symptomatic hardware. To determine long-term functional outcome, a modified Hospital for Special Surgery knee score was used. At an average of 36 months, good to excellent knee scores were observed in 17 of 22 patients. We conclude that all attempts for preservation of bone substance and precise reconstruction of the extensor should be attempted, reserving total patellectomy as a salvage procedure.

Diaphyseal forearm fractures treated with and without bone graft.

BACKGROUND The purpose of this study was to determine whether the acute bone grafting of diaphyseal forearm fractures decreases the incidence of nonunion and reduces the time to union. Although the traditional treatment of comminuted radius and/or ulnar shaft fractures involves bone graft, a recent report called into question this practice. PATIENTS A database search was used to identify all acute diaphyseal forearm fractures presenting to an urban Level I trauma center between 1988 and 1996. All radius and/or ulnar shaft fractures, as well as all Monteggia and Galeazzi fracture-dislocations, in patients with closed physes were included. The charts and operative reports were available for 64 diaphyseal forearm fractures in 49 patients. Fifty-six fractures were followed for at least 1 year beyond clinical and radiographic union. The injuries were treated with open reduction and plate fixation by experienced orthopedic traumatologists. All noncomminuted fractures were treated without bone graft. For the comminuted fractures, the decision to use bone graft was left to the discretion of the operating surgeon. RESULTS Overall, 55 of 56 fractures (98%) achieved union at a mean of 49 days (range, 19-123 days), with the only nonunion occurring in a patient with a closed, noncomminuted Galeazzi injury. Among the 20 noncomminuted fractures, all of which were treated without bone graft, 19 (95%) achieved union at a mean of 50 days (range, 19-102 days). Among the 36 comminuted fractures, all 25 treated without bone graft achieved fusion at an average of 50 days (range, 20-123 days) and all 11 treated with bone graft achieved union at an average of 45 days (range, 22-67 days). No statistically significant difference in the incidence of nonunion or time to union was noted between fractures that were treated with and without bone graft. CONCLUSION Acute bone grafting of diaphyseal forearm fractures did not affect the union rate or the time to union.

Early exchange intramedullary nailing of distal femoral fractures with vascular injury initially stabilized with external fixation.

Fracture of the femur with accompanying arterial injury represents approximately 1% of all femoral fractures. Controversy exists regarding the choice of fixation and the sequence of fixation and vascular repair. We report on the treatment of six patients with seven distal femoral fractures and angiographically documented arterial injuries treated over a 20-month period. The treatment protocol consisted of angiography followed by provisional external fixation and early primary exchange to an intramedullary nail. Five of the seven fractures were open. Three fractures were caused by blunt trauma, and four were secondary to shotgun blasts. Average follow-up was 12 months (range, 6-25 months). All fractures healed with an average time to union of 25 weeks. There were no complications related to the vascular repair. One case of an acute deep infection resolved after debridement and placement of polymethylmethacrylate cement beads impregnated with antibiotics and a course of intravenous antibiotics. All patients returned to their previous levels of activity. Based on the results of our experience with a small group of patients, we feel that this treatment protocol will prove to be a safe and efficient method of management of these difficult injuries.

Three-dimensional Computerized Tomographic Demonstration of Bilateral Atlantoaxial Rotatory Dislocation in an Adult: Report of a Case and Review of the Literature

Summary: A rare case of bilateral atlantoaxial rotatory dislocation (Fielding type V) in an adult is presented. The diagnosis was rapidly made by computed axial tomography. Prior reports of this entity have not clearly defined the pathoanatomy, which in our case was confirmed by three-dimensional tomographic reconstruction. We offer a clarification of the anatomic lesion and a discussion of this injury, which may make recognition and treatment of future cases easier.

Patterns of injury and disability caused by forklift trucks

Over a 7-year period, 34 patients were treated at the Southern New Jersey Regional Trauma Center for forklift-related injuries, ranging from minor contusions to multiple organ-system trauma. Hospital and rehabilitation courses were prospectively evaluated, documenting long term impairment of function and disability. Patients injured by falling from forklifts generally had less severe injuries, requiring fewer surgical procedures, shorter hospital stays, and less overall disability, than patients who received crush-type (object-oriented) injuries. The more serious injuries were most frequently caused by a forklift striking or running over the patient. There were strong correlations between the Injury Severity Score assessed upon initial evaluation and subsequent length of hospitalization, degree of disability, and extent of functional impairment after recovery. These findings support the enforcement of existing safety precautions for the operation of forklift trucks.

Orthopaedic trauma education: visions for the future through the OTA. Orthopaedic Trauma Association.

As the trauma center system continues to expand, not only will the requirement for more and better trained trauma surgeons increase, but the means of educating them will need to become more standardized. The general surgeons recognized this many years ago, but orthopaedic trauma has lagged in its efforts to present a coordinated academic and clinical program to residents and fellows. The Orthopaedic Trauma Association has made a move to develop guidelines which may be used by training programs in an effort to improve the educational standards of this subspecialty. The recruitment and retention of young orthopaedic trauma surgeons remains an issue.

Posterior stabilization of the pelvis with sacral bars

Severe injuries to the posterior elements of the pelvis can be devastating. If unstable injuries are left untreated, they may predispose the patient to increased morbidity and mortality from immobilization. The late sequellae of malunion and pain in the posterior aspect of the pelvis may have significant impact on the quality of life for the injured party. Stabilization of posterior sacroiliac disruptions and sacral fractures can be performed safely and effectively when the right indications are present through the use of posterior sacral bars. This technique avoids some of the possible complications of other stabilizing techniques, such as the use of sacral screws and the double cobra plate. This fixation takes place behind the distal lumbar spine and sacrum, and subsequently avoids potential injury to nerve roots and the central sacral canal that lie anteriorly.