Stress fractures of the medial tibial plateau

In a review of thirty-six patients with fifty-seven stress fractures of the medial tibial plateau, I found that limitation of activity was universally successful in treatment. Neither displacement of the fracture nor recurrence of symptoms after healing were seen. The main danger in this entity is misdiagnosis and inappropriate treatment.     

Stress fractures of the femoral neck

Stress fractures of the femoral neck are uncommon injuries. In general these injuries are seen in two distinct populations: (1) young, healthy, active individuals such as recreational runners, endurance athletes, or military recruits; and (2) the elderly who have osteoporosis. Stress fractures can be classified as either fatigue or insufficiency fractures and result from untoward cyclic loading or impaired bone quality. The key to treatment is early diagnosis, which may require scintigraphy or magnetic resonance imaging. Nondisplaced compression type stress fractures can be treated nonoperatively with protected weight-bearing and frequent radiographic followup. Tension type stress fractures should be stabilized internally to prevent the adverse consequences of fracture displacement.     

406 femoral fractures in children

406 fractures of the femur in persons younger than 17 years of age were treated at Haukeland University Hospital, Bergen, from January 1980 to December 1993. The incidence was 35/100,000 per year; 57/100,000 for boys, and 24/100,000 for girls. No significant changes in the incidence occurred during the study period. 70% of the fractures occurred in boys. 78% had an isolated fracture, while 7% had other fractures, 7% head injuries and 8% injuries of multiple organs as well. Traffic accidents accounted for 35% of the fractures. 65% of the femur fractures were treated by skeletal traction (mean hospitalisation 30 days), 21% were operated on initially (hospitalisation 12 days), and 14% were given early spica cast (hospitalisation three days). The results of the treatment were generally satisfactory. Neither anisomelia (8.5% more than 10 mm) nor malrotation (12% more than 10 degrees) of the femur was a serious problem, but the length of time the patients were hospitalized was rather long.     

Epidemiology and outcome of tibial diaphyseal fractures in footballers

A retrospective analysis of tibial diaphyseal fractures caused by football was undertaken to establish the epidemiology and severity of these common injuries. Analysis showed that the commonest fracture types were Tscherne C0 and C1 fractures and that only 73.9 per cent of the patients had unimpaired sporting function after the injury. The time to return to football was significantly related to the severity of the fracture but there was no correlation with the skill of the player. The time to return to football for the C0 fractures averaged 7-8 months and it is therefore suggested that it is unlikely that any player will return to football in the same season.     

Outcome of femoral shaft fractures in the elderly

Published literature on fractures of the femoral shaft has reported results of treatment stratified by fracture type or treatment type. The current study analyzes the outcome of fractures of the femoral shaft in elderly patients. One hundred thirty-eight patients older than the age of 65 years sustained femoral shaft fractures. Ten percent of the patients had associated injuries. The majority of the patients had significant prefracture medical problems. Nonsurgical treatment was used in 29 cases. Surgical treatment in 109 patients consisted of cerclage wires in 13 cases, plates and screws in 58 cases, intramedullary nails in 26 cases, and long stem prostheses in 12 cases. Complications of treatment occurred in 46% of patients. The type of treatment did not influence the frequency of complications. Twenty percent of patients died within 6 months of the fracture. There was a significant difference in the age of the patients who survived compared with those who did not survive. The mental status of the patient was also a major determinant of survival. Alert and oriented patients had a much better chance of survival. The outcome of fractures of the femoral shafts cited in the literature is different from the results seen in this population of elderly patients. The observed complication rate of 46% and mortality rate of 20% in this series is similar to those reported for intertrochanteric fractures and femoral neck fractures. Age and mental status are important determinants in the survival of the patient regardless of the treatment administered.     

MR imaging of tibial plateau fractures

Magnetic resonance (MR) images of five patients with acute tibial plateau fractures are presented and correlated with both clinical examination and findings at surgical intervention. The role of MR imaging in the evaluation of both osseous and soft tissue deformity in acute trauma, specifically in patients with tibial plateau fractures is discussed. The value of MR imaging as an alternative to computed tomography and arthroscopic evaluation of these patients is emphasized.     

Minimally invasive osteosynthesis of fractures of the tibial head

The role of closed reduction techniques in tibial plateau fractures was evaluated retrospectively in a group of 33 patients. The patients had mainly B fractures (AO classification) and were treated by the arthroscopic reduction technique (n = 10) or by reduction under fluoroscopic control (n = 23) and transcutaneous screw fixation. The 21 patients with an average follow-up of 34 months (minimum 1 year) were reviewed. Using clinical and radiological criteria, 19 results were considered excellent to good. One patient with a residual deformity was revised with a total knee and 1 patient with an anatomical result had arthritic pain in the knee operated on. Arthroscopic reduction had no advantages over reduction under fluoroscopic control in this study. The specific value of the technically demanding endoscopic procedure should be questioned, as percutaneous reduction under fluoroscopic control may achieve comparable results in the majority of these cases.     

Is it possible to predict limb viability in complex Gustilo IIIB and IIIC tibial fractures? A comparison of two predictive indices

The patient with severe lower limb trauma presents a management dilemma; whether to amputate primarily or to attempt limb salvage. In recent years, many predictive indices have been published which purport to identify limbs which are non-viable. We retrospectively applied two recently described indices, the Mangled Extremity Severity Score (MESS) and the Limb Salvage Index (LSI), to 54 limbs in 50 patients with either Gustilo IIIB or IIIC complex tibial fractures. There were 22 amputations (40.7 per cent) in the series. The mean MESS score in the limb salvage group was 3.8 (range 2-10), and the mean MESS score in the amputation group was 7.7 (range 4-13) (P < 0.0001). The mean LSI score in the limb salvage group was 3.6 (range 3-8), and the mean LSI score in the amputation group was 6.9 (P < 0.01). However, in the group with MESS scores > 7 (which recommends amputation), there were three limbs which were salvaged with acceptable functional outcome. Similarly, in those with LSI scores > 6 (which recommends amputation), there were seven limbs successfully salvaged. A MESS > 7 offered a greater relative risk of amputation (9.2) than a LSI score > 6 (5.3). We found both indices of use in predicting limb salvage and functional outcome. However, neither is sufficiently accurate to be considered absolutely reliable in clinical practice.     

Primary free-flap cover of open tibial fractures

Eosinophils are important cells of inflammatory infiltration in respiratory tract of asthmatics patients. Rantes is a potent chemotactic agent for eosinophils. It belongs to the chemokine family. Heparin has been reported to diminish size of allergen skin tests and decrease response to allergen bronchoprovocation in allergic asthma. We have found that heparin diminished late phase of allergic reaction and inhibits allergen induced increase in specific and nonspecific bronchial hyperresponsiveness. In order to explore the mechanism involved in these protective effects we studied the influence of heparin on eosinophil chemotaxis induced by Rantes and FMLP. Eosinophils were isolated from peripheral blood of 12 asthmatic donors. Chemotaxis was evaluated using polycarbonate filters in 48-well chemotactic chamber. The table shows the results (*) p < 0.05. [table: see text] Ten minutes exposure of eosinophils to heparin was sufficient for inhibition. Removal to heparin by washing the cells ablated observed effects. Preincubation of Rantes or FMLP with heparin did not induce any significant changes in eosinophil chemotaxis. Heparin alone did not posess any chemotactic activity for eosinophils. Our results suggest that heparin ameliorate allergic inflammation by inhibition of eosinophil flux and this inhibition is a surface phenomenon.     

Hemarthrosis and hip joint pressure in femoral neck fractures

In a prospective clinical study the intraarticular pressure of 55 patients with intracapsular femoral neck fractures was measured intraoperatively with the hip in different positions. Intraarticular hemarthrosis was quantified by a preoperative sonography examination. In 75% of the patients, increased intraarticular pressure caused by the hemarthrosis was found. The spontaneous median pressure increased significantly from 22 mm Hg with extension (28 mm Hg) and internal rotation of the hip joint (56 mm Hg). The lowest pressure was found in 70 degrees flexion (15 mm Hg). The median pressures increased within the first 24 hours after injury from 26 mm Hg in the first 6 hours to 46 mm Hg from 7 to 24 hours. Even in the first and second weeks after trauma, increased median pressures were detected (8.5 mm Hg and 13 mm Hg, respectively). No significant difference was found between undisplaced and displaced fracture types. Because increased joint pressure in other studies correlates with reduced perfusion of the femoral head, it can be deduced that reduction maneuvers without capsulotomy can compromise the circulation of the femoral head. Capsulotomy and osteosynthesis of the femoral neck at the earliest time possible is the best prophylaxis of tamponade. If the osteosynthesis is delayed, a preoperative sonography after admission and a control sonogram after 6 hours is recommended. In the event of relevant hemarthrosis, immediate therapeutic drainage is suggested for patients who will receive joint conserving osteosynthesis.     

Nonreamed flexible locked intramedullary nailing in tibial open fractures

Thirty-nine open unstable tibial shaft fractures were treated with a nonreamed flexible locked intramedullary nail between 1992 and 1995. There were 23 Grade I, 12 Grade II, three Grade IIIA, and one Grade IIIB fractures. The average time of followup assessment was 24 months. The average time to fracture union was 24 weeks. Complications were related in most cases to fractures with highly unstable patterns and extensive soft tissue lesions. There were five (12.5%) delayed unions and one (2.5%) nonunion. Deep infections developed in three (7.7%) patients. One patient required an additional procedure to correct a varus malunion. There were no implant failures. It was concluded that nonreamed flexible locked nailing provides effective control of axial and rotational stability in unstable Grades I to IIIA open fractures with acceptable union rates and a low incidence of complications secondary to the fixation system.     

Indications for surgical treatment of tibial condyle fractures

The residual radioanatomic changes influencing the functional, subjective, and clinical outcome of 131 tibial condyle fractures were studied. Clinical function was found to deteriorate rapidly with increasing values of residual medial tilt of the tibial plateau, whereas lateral tilt of the plateau was well tolerated up to 5 degrees. Articular step-off up to 3 mm and condylar widening up to 5 mm had no adverse effects. Seventy percent of knees with moderate or severe instability were functionally unacceptable. It was concluded that a medial unicondylar fracture with any displacement, and all medially tilted bicondylar fractures, should be operated upon. In fracture of the lateral condyle, open reduction and internal fixation is indicated when lateral tilt or valgus malalignment exceeds 5 degrees, articular step-off exceeds 3 mm, or condylar widening exceeds 5 mm. The same limits apply to laterally tilted bicondylar fractures, provided that the medial condyle is undisplaced. Any displacement seen in the axial bicondylar fracture is an indication for surgical treatment. If there is any mediolateral instability in the extended knee joint after rigid internal fixation, repair of a collateral ligament should be considered. An avulsed anterior cruciate ligament should be fixed, if pathologic laxity exists, but the torn ligament can be ignored and reconstructed later if needed.     

Surgical treatment of patients with open tibial fractures

Open tibial fractures are true surgical emergencies because of the risk of extensive infection to bone and devitalized soft tissue. The most serious consequence of open tibial fractures is osteomyelitis, which usually can be prevented by prompt surgical intervention within six to eight hours after injuries occur. Open tibial fractures often are the result of trauma from motor vehicle collisions, farm accidents, falls from heights, or gunshot wounds. Initial management of patients with multiple trauma injuries focuses on their life-threatening injuries before or during orthopedic surgical intervention for open tibial fractures. Orthopedic surgeons often work in collaboration with general, vascular, and plastic surgeons and perform multiple surgical procedures (eg, fasciotomy procedures for compartment syndromes, irrigation and debridement of wounds, application of external fixation devices, placement of intramedullary nails, possible limb amputations). The type and extent of open tibial fractures and soft tissue injuries determine the best treatment options for patients. Perioperative nurses should help patients focus on treatment choices for their open tibial fractures that ensure optimal surgical outcomes and maintain their quality of life.     

Patient self-assessment of tibial plateau fractures in 40 older adults

The prevalence of refractory partial seizure Thai patients at Prasat Neurological Institute was retrospectively from patient charts from January 1995-December 1996 and further prospectively analysed. All epileptic patients were screened by direct questions regarding the anti-epileptic drugs (AEDs) regimen, the frequency, nature of seizure attacks and risk factors of seizure. The criteria of clinical refractory partial seizure was defined as partial seizure which cannot be controlled by a combination of at least two AEDs for four weeks. The results were 3,018 cases of total epileptic patients out of 300,008 visits. These were classified as 2,802 cases of generalized seizures (92.8%), 184 cases of partial seizures (6.1%), and 32 cases of unclassified seizures (1.1%). In the partial seizures group, the number of clinical refractory partial seizures was found to be 48 cases (26.1% of partial seizure). We found that the major risk factor of refractory partial seizures was lack of therapeutic AEDs blood level monitoring (64.5% of cases) and the other risk factors were lack of compliance, loss of follow-up but continued medication, concomitant medication, and improper drug storage. AEDs dosage was adjusted until the blood levels were in the therapeutic range, and correction of other risk factors and patient counseling was given. The number of true refractory partial seizures was reduced to 10 cases (5.4% of partial seizure). This procedure revealed that AED blood level monitoring and correction of other risk factors were essential in controlling seizure frequency. Thus, the prevalence of true refractory partial seizure in our study was 3.3 cases of refractory partial seizure per 1,000 cases of the seizure population. We recommend that AEDs blood level monitoring and exclusion of other risk factors should be added to the criteria for the definition of refractory partial seizures. This criteria should be applied when considering the use of new AEDs as an add-on therapy in refractory Thai patients.     

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.     

Outcome after hemiarthroplasty for femoral neck fractures in the elderly

A prospective outcome study was performed on 270 patients, 65 years of age and older, who sustained a femoral neck fracture and underwent hemiarthroplasty. The treatment compared was the use of a noncemented unipolar versus either a cemented or a press fit bipolar prosthesis. The outcome variables assessed included the occurrence of a postoperative complication, length and cost of hospitalization, and function in various quality of life measurements. Patients who underwent bipolar hemiarthroplasty with either a cemented or a press fit prosthesis had better pain relief and function than patients who had a noncemented unipolar prosthesis at a minimum of 24 months after surgery. However, the mean hospitalization cost for patients who had a bipolar prosthesis was $12,290 compared with $8876 for a unipolar prosthesis.     

The cast-brace treatment of femoral shaft fractures

Ninety-eight fractures of the shaft of the femur were seen in one unit over the two years 1974 and 1975, and the results have been assessed in sixty-nine. Of these, thirty-eight were treated by skeletal traction in a Thomas's splint followed by skin traction, and thirty-one by skeletal traction followed by a cast-brace. The technique of application is described in some detail. The average time for application of the cast-brace was six weeks after the injury, the time in hospital eight weeks and the time till removal fifteen weeks. The patients selected for a cast-brace were in hospital for just over half the time of the others and their fractures on average united more quickly, though with some trouble from angulation of fractures of the uppermost third of the shaft. It is concluded that when used with all the judgment and skill it demands, the cast-brace method is a great advance in conservative treatment.     

Femoral nerve block in extracapsular femoral neck fractures

We randomised 50 patients with extracapsular fractures of the femoral neck to receive either a bupivacaine femoral nerve block or systemic analgesia alone. A femoral nerve block was found to be an easy and effective procedure which significantly reduced perioperative analgesic requirements and postoperative morbidity.