How many severely injured multiple-trauma patients can benefit from the biomechanical advantage of early mobilization following femoral intramedullary nailing?

The benefit of early operative stabilization of femoral fractures is established in patients with multiple injuries. In the last few years the unreamed femoral nail is favoured for internal fixation of femoral fractures despite pathophysiological concerns. The foremost advantage of femoral nails compared with plate fixation is the possibility of early full weight bearing. The aim of this retrospective study was to investigate, under consideration of the severity of injury, the extent of injury, and the clinical course, if multiple injured patients with concomitant femoral fractures benefit from the preferred intramedullary nailing with early weight bearing. Three hundred and two (23.8%) out of 1271 multiple injured patients (ISS > 17) had a concomitant femoral fracture. Fourty-seven out of 302 patients were children under 16 years of age, remaining 255 patients. Eighteen out of 255 patients died within the first 21 days after trauma and 66 patients required mechanical ventilation for more than three weeks (171/255). Thirty patients suffered from severe head injury (AIS-head > 3) and seven from severe pulmonary contusion with concomitant abdominal injury (134/255). Two patients had grade III open femoral fractures with vascular injury. Ipsilateral unstable pelvic fractures were seen in 11 patients, seven patients had ipsilateral intraarticular femoral fractures, and ipsilateral intraarticular fractures of the lower leg or foot were observed in 40 patients (74/255). The results demonstrate, that only 74 (29%) out of 255 multiple injured patients (> 16 years of age) had a theoretical benefit of early weight bearing. Seventy percent of the patients did not benefit from intramedullary nailing considering full weight bearing. With regard to pathophysiological concerns alternative methods of fracture fixation should be discussed for these patients. Primary fracture fixation with external fixators and secondary internal fixation proved to be a save alternative method. The complication rate of plating is comparable to intramedullary nailing but associated with less severe systemic risks. Primary plating of femoral fractures would not delay mobilization of most multiple injured patients.     

Internal derangement of the knee after ipsilateral femoral shaft fracture: MR imaging findings

OBJECTIVE: This study uses magnetic resonance (MR) imaging to delineate the types and frequencies of injuries seen in the knee after ipsilateral femoral shaft fracture. We also compare the results of the orthopedic knee examination with the MR findings. DESIGN AND PATIENTS: MR imaging of the ipsilateral knee was performed on 34 patients with closed femoral shaft fractures. Indications for knee MR imaging included knee pain at the time of fracture, soft tissue swelling or an effusion of the knee, or a positive knee examination under anesthesia. The patients had a mean age of 27 years and all were stabilized with intramedullary nails. Imaging was performed a mean time of 2.5 days after surgery. All patients had knee examinations done under anesthesia, and the MR results were compiled and compared with the clinical examinations. RESULTS: Ninety-seven percent of patients demonstrated knee effusions. Twenty-seven percent of patients demonstrated meniscal tears, with the posterior horn of the medial meniscus most frequently torn. The medial collateral ligament was the most frequent site of ligamentous injury (38%) followed by the posterior cruciate ligament (21%). Fifty percent of patients had injuries of the extensor mechanism. Bone bruises were noted in 32% of patients. Articular cartilage injuries were confined to the patella in four cases. One occult tibial plateau fracture and one meniscocapsular separation were seen. CONCLUSIONS: There is a common incidence of both ligamentous and meniscal injury to the knee after ipsilateral femoral shaft fracture. MR imaging can be useful in assessing the extent of injury, and may reveal findings unsuspected after clinical examination of the knee.     

Traumatic ostearthritis of the hip joint and its treatment (author's transl)

The author describes the various origins of osteoarthrosis following hip joint injuries. Since beginning osteoarthrosis can't be stoped, he emphasizes the surgical treatment of joint fractures including accurate reduction and stabilization of the fragments. In respect of this, intracapsular fractures of the neck of the femur always require a stabile fixation. In all cases the micro-injuries of the articular cartilage should be considered. The different possibilities of post-traumatic degenerative arthritis are discussed and the methods of operative procedures presented.     

Recent references

We studied endogenic factors for the occurrence of cervical hip fractures in 256 patients. 230 underwent hemiarthroplasty, and 26 were treated with internal fixation or without surgery. The condition of the fractured hip and of the ipsilateral knee, as well as the mobility of the patient before the fracture, were studied in all 256 patients. The removed femoral heads were examined, photographed and radiographs were taken with sensitive film. The acetabulum and the femoral head were macroscopically normal in all 230 cases and there was no radiographic evidence of arthrosis. 64% of the patients were fully mobile before the fracture, 34% were mobile with the aid of a cane and 2% were dependent. In 88%, the ipsilateral knee was normal both clinically and radiographically, and in 12%, there was moderate arthrosis. When comparing the mobility before the fracture and the condition of the ipsilateral hip and knee in 100 patients having a cervical fracture with 100 patients having a trochanteric fracture matched for age and sex, we found that a normal hip joint was sine qua non while a normal ipsilateral knee and a fully mobile individual were important additional conditions for the occurrence of a cervical hip fracture, instead of a trochanteric one, after a fall in an elderly person.     

Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury

The results were reviewed for 259 patients who had open reduction and internal fixation of 262 displaced acetabular fractures within twenty-one days after the injury. Two hundred and fifty-five hips were followed for a mean of six years (range, two to fourteen years) after the injury; the remaining seven, which clearly had a poor result, were followed for less than two years. According to the classification of Letournel and Judet, associated fracture types accounted for 208 (79 per cent) of the fractures, with both-column fractures being the most common type (ninety-two hips; 35 per cent). Two hundred and fifty-eight hips were operated on with a single operative approach (Kocher-Langenbeck, ilioinguinal, or extended iliofemoral). The four remaining hips were operated on with a Kocher-Langenbeck as well as an ilioinguinal approach. The reduction was graded as anatomical in 185 hips (71 per cent). The rate of anatomical reduction decreased with increases in the complexity of the fracture, the age of the patient, and the interval between the injury and the reduction. The over-all clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. The clinical result was adversely affected by associated injuries of the femoral head, an older age of the patient, and operative complications. It was positively affected by an anatomical reduction and postoperative congruity between the femoral head and the acetabular roof. Osteonecrosis of the femoral head was noted in eight hips (3 per cent), and progressive wear of the femoral head was seen in thirteen (5 per cent). Subsequent operations included a total replacement of seventeen hips (6 per cent), an arthrodesis in four (2 per cent), and excision of ectopic bone in twelve (5 per cent). These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved. An increase in the rate of anatomical reduction and a decrease in the rate of operative complications should be the goals of surgeons who treat these fractures.     

Risk of pelvic injury from femoral neck guidewires

Many of the devices used in the internal fixation of femoral neck fractures are cannulated and require the initial placement of one or more guidewires for accurate positioning. These wires are occasionally advanced inadvertently through the hip joint and the acetabulum. Pelvic visceral damage may follow. To assess this risk, we inserted three guidewires to a depth of 16 cm into each femoral neck of ten cadavers and explored the pelvis during autopsy. Thirty-two of the 60 guidewires had penetrated a pelvic organ. The literature on intrapelvic injuries associated with hip surgery is reviewed, and suggestions are offered on the avoidance of pelvic penetration during hip fracture fixation.     

Fractures after total knee joint endoprosthesis. Results of treatment with various stabilizing methods

In 20 patients with a fracture of femur or tibia 5.2 years after arthroplasty of knee the results of the operative treatment are presented. The results show that especially bone damaging diseases as rheumatoid arthritis, osteoporosis and the loosening of the endoprosthesis are favorable for the fracture during the follow-up. The conclusion of the investigation shows that in younger patients the external fixation by plates and screws is the preferential treatment, in elderly people or comminuted fracture an internal fixation, also in combination with an additional osteosynthesis, allows a fast mobilization. The number of observed complications is higher than in primary knee arthroplasty, the full weight bearing 1st delayed. The rate of further operations and unsatisfactory results is also higher being affected by the high mean age of the operated patients (73.4 years). The possible use of a total femur implant must be discussed critically because only an individual production can avoid further damage of the parts of the joint that were not concerned by the fracture.     

alpha B-crystallin and hsp25 in neonatal cardiac cells--differences in cellular localization under stress conditions

OBJECTIVES: The aim of this study was to determine (a) whether delay in femur fracture stabilization beyond twenty-four hours in patients with head injury increased the risk of pulmonary complications and (b) whether immediate (up to twenty-four hours) femur fracture stabilization increased the risk of central nervous system (CNS) complications. DESIGN: Retrospective analysis. MATERIALS AND METHODS: Thirty-two patients with femur fracture and head injury were identified. Fourteen underwent immediate stabilization of their fractures, and eighteen underwent delayed (four-teen patients) or no (four patients) stabilization of their fractures. RESULTS: In the immediate stabilization group, five patients had severe head injuries [Glasgow Coma Score (GCS) < or = 8] and nine had mild head injuries (GCS > 8). In the mild head injury group, no patient had a pulmonary complication and one had a CNS complication. In the severely head-injured group, one patient had a pulmonary complication and no patient had a CNS complication. In the delayed stabilization group, six patients had mild head injuries (GCS > 8) and twelve had severe head injuries (GCS < or = 8). In the mildly head injured group, one patient had a pulmonary complication, two patients had CNS complications, and one patient died. In the severely head injured group, nine patients had pulmonary complications, three patients had CNS complications, and one patient died. Logistic regression identified delay in femur stabilization as the strongest predictor of pulmonary complication (p = 0.0042), followed by severity of chest Abbreviated Injury Score (AIS; p = 0.0057) and head AIS (p = 0.0133). Delaying fracture stabilization made pulmonary complications forty-five times more likely. Each point increase in the chest AIS and head/neck AIS increased the risk of pulmonary complication by 300 percent and 500 percent, respectively. A statistically significant predictor of CNS complications could not be identified by using logistic regression. CONCLUSION: Delay in stabilization of femur fracture in head-injured patients appears to increase the risk of pulmonary complications. However, due to selection bias in this patient sample, this question cannot be definitively answered. Early fracture stabilization did not increase the prevalence of CNS complications.     

Percutaneous fluoroscopic screw fixation of acetabular fractures

Over a 2-year period eight patients underwent percutaneous fluoroscopic fixation of their acetabular fractures. Average patient age was 43 and mean ISS was 27. Mean blood loss was less than 100 ml. There were five transverse fractures, one affecting both columns, one anterior column-posterior hemitransverse and one T-type fracture. There were two ipsilateral femoral and two ipsilateral tibial fractures. Mean follow-up was 15 months. Three broad patient groups were identified. One patient died, one was lost to follow-up, four had full range of motion of the affected hip, one had good range with Brooker II heterotopic ossification and one was wheelchair-bound with Brooker IV heterotopic ossification. The technique, which requires only cannulated screws and fluoroscopy, is described.     

An algorithm for the management of femoral neck fractures

The choice of total hip arthroplasty should probably be reserved for those rare patients with preexisting osteoarthritis of the hip in the setting of a subcapital hip fracture. Additionally, relative indications for total hip arthroplasty may include the presence of contralateral hip disease; the presence of metabolic bone disease, which may controvert internal fixation or reasonable results with endoprosthetic replacement; and those patients with high activity expectations or life expectancy greater than 5 years. Given the diminished performance of hemiarthroplasty with time and activity, it may be argued that the most cost effective solution to the subcapital hip fracture in the majority of patients may be the reduction and internal fixation pathway, with elective conversion, when necessary, of the approximately 25% of patients who suffer avascular necrosis to total hip arthroplasty. It appears that hemiarthroplasty is best suited for the elderly household ambulator, whereas total hip arthroplasty is the better alternative either as the elective solution to failed internal fixation of femoral neck fractures or in the occasional community ambulator with high activity expectations and irreducible femoral neck fractures. Younger patients, and those with minimally displaced fractures, should be treated with internal fixation in an attempt to preserve the natural hip joint.     

Intertrochanteric femoral osteotomy with concentric reduction of the femoral head in treatment of residual congenital acetabular dysplasia

A method of classification based upon increase of the anteversion and valgus deformity of the upper femur associated with a dysplastic acetabulum and subluxation of the femoral head demonstrates 4 main groups: I or II in patients 1 to 3 years of age; III, patients approximately 2 years of age; IV, patients with absolute contraindication for surgical intervention. The Monticelli technique employs a Kirschner wire for the internal fixation and incorporates it in a hip spica. The results of the surgical treatment are very gratifying when classification and specified indications are correct. In follow-up observations ranging from 3 to 11 years, with an average of 7 years, there were practically no complications other than a few superficial skin infections.     

Transpedicular fixation with Zielke instrumentation in the treatment of thoracolumbar and lumbar injuries

STUDY DESIGN: Sixty-five patients who underwent transpedicular fixation for thoracolumbar and lumbar injuries were studied for type of injury, the severity of paralysis, the degree of postoperative correction, and instrumentation failures. OBJECTIVES: To evaluate the surgical approaches and the selection of instrumentation to determine indications for using the transpedicular fixation procedure. SUMMARY OF BACKGROUND DATA: Various transpedicular fixation devices have been used for different type of injuries, and satisfactory postoperative results were not obtained in some studies. METHODS: Forty patients had burst fractures, 19 had fracture dislocations, and six had chance-type fractures. An anterior decompression procedure was used for most cases of burst fracture and some cases of fracture dislocation where anterior compression factors were present. The Zielke or modified Zielke system was used as an internal fixator for posterior segmental fixation. RESULTS: No patient had neurologic deterioration after surgery. Twenty of 28 patients with incomplete lesions improved postoperatively according to Frankel grades. The instrumentation failed in only one patient, in whom a nonunion developed. CONCLUSION: With transpedicular fixation, it is possible to provide solid internal fixation that is circumscribed to the injured vertebral segments. The elasticity of the Zielke rod makes it an excellent transpedicular fixation device because it is easily attached and reduction is easily performed. Anterior decompression with fusion needs to be used with transpedicular fixation in the treatment of injuries (especially burst fractures).     

Palmar fracture dislocation of the proximal interphalangeal joint

Palmar fracture dislocation of the proximal interphalangeal joint is uncommon. Thirteen patients treated for this injury were retrospectively reviewed. There were 9 acute injuries. Seven were treated by closed reduction and percutaneous pin fixation and 2 were treated by open reduction and internal fixation. The 4 chronic injuries (more than 1 month after injury) were treated with open reduction and soft tissue reconstruction. The length of follow-up averaged 55 months. Eight patients were free from pain. Postoperative proximal interphalangeal motion averaged 91 for the acute injuries and 70 degrees for the chronic injuries. Follow-up radiographic findings were notable for an increased height of the middle phalangeal base in 6 patients, articular irregularity in 4, and residual subluxation in 2; however, these changes did not correlate with the clinical results. Complications included loss of reduction in 1 patient, progressive swan neck deformity in 1, and development of an average 25 degrees extension lag of the distal interphalangeal joint in 5.     

Fractures of the tibial tuberosity in adolescents

The cases of fourteen adolescents with fifteen physeal fractures of the tibial tuberosity were reviewed to more accurately define specific fracture patterns, to establish treatment for the different types, and to determine the incidence of complications. A modified classification scheme with a greater emphasis on intra-articular extension of the fracture and communution of the tuberosity was devised. Closed or open reduction, as necessary, gave satisfactory results. The primary indications for surgery were: (1) displacement of one or more fragments of the tuberosity anterosuperiorly, and (2) extension of the fracture through the proximal tibial ossification center into the knee joint, with disruption of the joint surface. There appears to be an increased incidence of pre-existing Osgood-Schlatter disease (ipsilateral and contralateral) in patients who have an acute tuberosity injury. Complications are rare. The theoretical possibility of the subsequent development of genu recurvatum appears unlikely, since most of these injuries occur when the physis of the tuberosity is undergoing normal closure.     

Increased plasma levels of substance P and disturbed water excretion in patients with liver cirrhosis

We describe a surgical technique for replacing the hip joint capsule using synthetic mesh after oncological resections of the proximal femur that resulted in gross intraoperative instability of the prosthetic reconstruction. The results of its use in 13 patients, 6 of whom also had pelvic resections, are described. These patients were selected from a total group of 88 patients undergoing proximal femoral replacement, 75 of whom did not require capsular replacement (none of these 75 patients have experienced dislocation). In the group requiring capsular reconstruction, 1 of 4 patients with bipolar hemiarthroplasty and 4 of 9 patients with total hip replacements experienced dislocation after operation. Of the dislocated total hip replacements, 1 remains chronically dislocated, and 3 were successfully stabilized by open reduction with further capsular augmentation. Given that the resections involved removal of most of the soft tissues stabilizing the hip joint, we believe that the technique of capsular reconstruction is useful in this difficult group of patients.     

Medical consultation for the elderly patient with hip fracture

BACKGROUND: This article describes a family physician geriatrician's perspective on the comprehensive management of hip fracture in frail elderly patients. Primary care physicians might be called upon to provide medical consultation for these patients. METHODS: Guidelines were developed by a combination of personal experience in consulting for several hundred elderly patients with hip fracture at a large community hospital, literature review using the key words "hip fractures," "aged," and "aged, 80 and over," and educational presentations for family practice residents. RESULTS AND CONCLUSIONS: Elderly patients with hip fracture offer a prime opportunity for comprehensive geriatric assessment. Intertrochanteric fractures are almost always treated with internal fixation, whereas femoral neck fractures can be treated by either fixation or by hemiarthroplasty. Hip fracture should be regarded as a surgical urgency, and generally operation should not be delayed, even if patients have serious comorbidity. The family physician can be instrumental in preparing the patient for surgery, preventing and treating complications, and assisting in the placement and rehabilitation of patients after hospital discharge.     

Displaced fractures of the glenoid fossa. Results of open reduction and internal fixation

Displaced fractures of the glenoid fossa are an uncommon and anatomically diverse group of injuries. Failure to restore anatomy in these fractures results in poor outcome in most cases. The success of a treatment protocol that encompasses appropriate preoperative imaging, injury pattern assessment, prudent approach choice, and a comprehensive reduction and fixation tactic was evaluated. Twenty-seven patients were assessed clinically and radiographically at a mean followup interval of 43 months from surgery. Anatomic reconstruction was achieved in 24 (89%) patients. Three patients had residual joint incongruities measuring 2 mm or less. The only perioperative complication was a partial superficial wound dehiscence. Two additional patients had infraspinatus palsies of indeterminate origin. Functional rating revealed six (22%) excellent, 16 (60%) good, three (11%) fair, and two (7%) poor outcomes. The fair and poor outcomes largely were related to associated injuries. These findings show that anatomic surgical reconstruction with a low complication rate and good functional outcome can be obtained for most patients with glenoid fossa fractures.     

Topological studies of the amino terminal modules of vitamin K-dependent protein S using monoclonal antibody epitope mapping and molecular modeling

Neglected fractures of the femoral neck, common in young adults in underdeveloped countries, may be complicated by nonunion or avascular necrosis (AVN). We treated 52 cases by open reduction, fixation by compression screw and a free fibular graft. The mean delay between injury and operation was 5.1 months. Of 40 fractures assessed at a mean of 58.8 months (24 to 153), 38 were found to be united and two, owing to surgical errors, were not. Seven of eight heads which were avascular before operation revascularised without collapse, while seven others developed AVN after the procedure. At the last follow-up considerable collapse was apparent in five femoral heads, and 11 hips had developed coxa vara. The fibular graft had fractured in four cases. The hip had been penetrated by the screw in six cases and by the graft in three. Hip function was excellent in seven patients, good in 21 and fair in seven. Five patients had poor results. Incorporation of the fibular graft was seen after four years: in many cases the graft had been almost completely resorbed. We recommend this procedure for the treatment of neglected fractures of the neck of the femur in young adults to reduce resorption of the neck, AVN and nonunion.     

Ipsilateral sternoclavicular joint dislocation and clavicle fracture

A case of an ipsilateral sternoclavicular (SC) joint dislocation and clavicle fracture is reported. Two hours postinjury an open reduction and internal fixation of the fractured clavicle was performed using a Kirschner wire plus a stainless steel cerclage wire. This was followed by a surgical repair of the SC joint capsule. The Kirschner wire and cerclage wires were removed 10 months later. The patient had complete recovery of shoulder function.     

The management of complex orthopedic injuries

As advancements are made in the prevention of automobile fatalities, an increase in the incidence of pelvic and lower extremity injuries has occurred. These remain the leading causes of impairment and loss of years of productive life. Pelvic trauma has a high initial mortality rate when severe. However, with early resuscitation and transport, more survivors arrive in our trauma centers harboring these injuries. Owing to early stabilization and mobilization of the traumatized patient, a decrease in complications in these patients has been noted. Both the trauma surgeon and the orthopedic trauma surgeon should work as a team and remain in continuous communication during the treatment of these patients. Open fractures are among the most difficult problems to manage; early and aggressive decisions can prevent a lifetime of complications and physical impairment. As previously stated, to obtain good outcomes, open fractures must be treated initially at the accident scene followed by timely transport to the trauma center for definitive care. It must be remembered that the golden time to prevent major complications is 6 hours. Intra-articular fractures of the lower extremity involve a major weight bearing joint. Post-traumatic arthritis and impairment develop in joints where joint congruity is not achieved. To preserve normal function, there should be articular congruity, stable fixation, axial alignment with the rest of the extremity, and restoration of full range of motion. Immediate stabilization of long bone fractures has many advantages in the multiply injured patient, such as improved long-term function, prevention of deep venous thrombosis and decubitus ulcer, decreased need for analgesia, and reduction in the incidence of adult respiratory distress syndrome and fat emboli. Patients with femoral shaft fractures should undergo immediate stabilization of the fracture within 24 hours of injury. We have presented a series of orthopedic injuries that have high mortality and high morbidity which, if not treated expediently, yield a high degree of impairment.