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.     

Detection of circulating epithelial cells in prostate cancer]

The authors report 10 segmental fractures of the femoral head associated with a dislocation of the hip. Using PIPKIN's classification, they noted 1 type I, 7 type II and 2 type III fractures. The initial treatment of the hip dislocation was conservative in all cases. Failure of reduction was noted in 6 cases and was complicated by fracture of the femoral neck in 2 cases. The attitude regarding the head fragment was: conservative in 5 cases, the reduction was considered satisfactory in 4 cases and poor in 1 case; surgical in the other 5 cases: screw fixation in 1 case, excision of the fragment in 1 case and prosthetic replacement of the femoral head in 3 cases. After a mean follow-up of 5 years, functional results were satisfactory in the majority of cases. The radiological assessment showed malunion without osteoarthrosis in one case and avascular necrosis of the femoral head in three cases. The authors propose a treatment policy based upon their experience and a review of the literature.     

Diagnosis and treatment of bone tumors complicated by pathological fractures

The article elucidates certain questions of modern methods of diagnosis and treatment of tumors of long tubular bones complicated by pathological fractures. The methods were used for the treatment of 41 patients. The authors emphasize the importance of such methods as radio- and angiography, punctional and trepanobiopsy, measurement of the intraosseous pressure. The efficiency of the ultrasound resection in association with cryodestruction for the treatment of the diseases mentioned is reported.     

Interface pressure measurements of support surfaces with subjects in the supine and 45-degree Fowler positions

The results of treatment of 35 intraarticular distal fractures of the femur are presented. Treatment was performed in 8 cases with a condylar plate, in 8 cases with dynamic compression screw (DCS), in 2 cases with two plates, in 9 cases with screws only, and eight times the fracture was treated with a combination of lag screws and locking nail. Examination took place at an average of 45.5 months after the accident. 19 patients had an isolated fracture, 8 patients one accidental injury and 8 patients had more than one fracture or were polytraumatised. In 75% of the patients treatment lasted for between day 1 and 5. We found 17.1% open fractures and had to face infections in 5.7% (two cases). Bone healing occurred in all fractures, the reported infections could be overcome by early revision and the use of gentamycin-PMMA beds. It is remarkable that locking nails were successfully used in 8 cases of fractures with intraarticular component of the distal femur.     

Pet ownership and future health

It is difficult to treat the intra-articular fracture of distal tibia or Pilion's fracture. From 1987 to 1995, 43 cases of Pilon's fracture were admitted and treated with different methods. After treatment, they had been followed up for 1 to 8 years. According to Riiedi's Classification, there were type I 12 cases, type II 21 cases and type III 10 cases. The methods used on these patients included manual reduction and plaster of paris immobilization, calcaneous tubercle traction and plaster of paris immobilization, open reduction and internal fixation with Kirschner wires, and open reduction and internal fixation with AO plate. The outcome was evaluated according to Ovadia's criteria, for type I fracture, 8 cases were treated with conservative method with a satisfactory rate of 79.17% and 4 cases were treated with operation with a satisfactory rate of 91.67%; for type II, conservative method for 12 cases and the satisfactory rate was 33.33%, and operation for 9 cases with a satisfactory rate of 70.37%; for type III, conservative method for 2 cases, with poor result, and operation for 8 cases with satisfactory rate of 79.17%. The indication for conservative treatment was type I fracture. It showed that for Pilon's fracture, the outcome of open reduction and internal fixation was superior to that of the conservative treatment, especially in those having internal fixation with AO plate.     

Emergency cervical cerclage after 20 weeks'' gestation: a retrospective study of 6 years'' practice in 34 cases

Bone metastases causing pain syndromes and imminent pathologic fractures are among the main reasons for radiotherapy in patients suffering from malignant tumors. The indication is much influenced by the radiologic findings. Surgical methods are to be chosen in the first place in cases of pathologic fractures or patients with a high risk of such fractures. Different authors recommend various therapeutic regimens. Effective pain control can be achieved with one single dose of radiation. Doses of 6 to 40 Gy applied in one to 19 days are also efficient. Side effects, especially nausea and vomiting occur in 25% of cases; this number rises to 50% in cases of half body irradiation. Visible changes of bone mineral density may be noticed about 6 weeks after termination of radiotherapy. About 70% of osteolytic metastases show progressive sclerosis whereas osteosclerotic lesions may show both increase or decline of bone mass. In spite many years of experience the optimal strategy for radiation therapy of bone metastasis has not been defined; further studies are needed.     

Effect of antenatal betamethasone and dexamethasone administration on fetal heart rate variability in growth-retarded fetuses

The results of the operative treatment of 27 humeral shaft fractures treated at the University of Louisville during a 2-year period were reviewed. The aim of this study was to analyze 1) the indications and results of surgical treatment, 2) the indications for nailing versus plating, and 3) the failures and their treatment (especially surgical nonunions). Indications for surgery were polytrauma patients (including open fractures, associated neurovascular injuries, associated ipsilateral forearm injuries) and isolated unstable fractures in which closed reduction failed. Plate and screw osteosynthesis was used in patients with proximal and distal fractures, in the presence of neurovascular injuries, progressive radial nerve palsy and failure of closed reduction due to interposition of soft tissue. Intramedullary antegrade nailing was preferentially used in polytrauma patients. Seven patients (25%) needed further surgery because of nonunion. The frequency was higher after plating (30%) than after nailing (20%), it was more common in comminuted fractures, middle third fractures and after insufficient distal locking. Exchange nailing resulted in union in 5 of the 7 cases. Although excellent results with low complication rates are reported in the recent literature following plate and screw osteosynthesis or locked intramedullary nailing, we found that operative treatment of difficult humeral shaft fractures is still fraught with a high complication rate.     

Urinary complications of the resectable cancers of the cervix uteri (author's transl)

The authors studied the urinary complications following 721 operations performed between 1960 and 1974 for cervix uterin carcinoma. The surgical method was the one used at the Fondation Curie according to the protocol of treatment. They have noted that: --first, the surgical act as primary treatment (672 cases) was innocuous, as this series showed only 0,6% of the severe complications; in contrast, when the surgery is performed for a recurrence after a total dose irradiation, the severe complications raised to 8%; --secondly, the uretero-hydronephroses following this type of surgery are relatively frequent on the systematic urograms, but most of them are quite asymptomatic and without later sequelae only 0,3% of them required a surgical treatment. The authors analyse the factors influencing the ureteral stenoses, especially the extent of lymphadenectomy and the associated external irradiation. They studied too the ureteral stenoses due to a local recurrence.     

Recent progress in orthopaedic managements of osteoporosis-related fractures

Recent progress in orthopaedic treatment of osteoporosis-related fractures was reviewed. In the femoral neck fractures, the bipolar prosthesis reduces acetabular erosion or central migration, and press-fit stem or cemented stem lowers the incedence of the stem sinking. In thorocanteric fractures, compression hip screws are most commonly used, however, in the cases of unstable fractures with severe osteoporosis, it is difficult to start weight-bearing within a few weeks of surgery because varus deformites or translations at the fracture site sometimes occur. To avoid this disadvantage, the gamma nail has been found to be more effective. In paralysis due to burst fractures of the osteoporotic spine, surgical decompression and spinal instrumentation is the established response. A special orthosis named 'rucksack type orthosis' has been devised and is used for patients who have back pain due to anterior bending posture of the trunk. In distal radius fractures, external fixators are now more frequently used.     

Operative treatment of the head of the tibia (author's transl)

Fractures of the tibial head should be treated operatively only in cases in which the result can be expected to be better than by conservative methods. The osteosynthesis should bring stability in order to allow training of the joint. Depending on the type of the fracture, screws or T-plates or L-plates can be used. In cases of depressed fractures it is most important to restore the level of the joint by underlying the impression by autogen spongiosa.     

Use of the Gamma nail in the treatment of fractures of the proximal femur

Fractures of the proximal femur are, more than ever, an important challenge in the field of traumatology. The Gamma nail, a combination of advantages of the sliding screw with the intramedullary nail, represents an efficient technique in the management of these fractures. A series of 224 fractures of the proximal femur in which this nail was used is reported. The average age of the patients was 79.2 years. The mean healing time was 68.2 days in 99.4% of the cases. The incidence of perioperative complications was 10.3% showing that, in most of the cases, the complications occurred because of poor technique. Postoperative complications occurred with an incidence of 14.1%. Seven cases of migration of a proximal screw, six shaft fractures, and one broken nail were the most important complications. The device allowed for early mobilization and full weightbearing of the affected hip regardless of the type of fracture. With adequate surgical technique and experience, the advantages of the Gamma nail increases as the complication rate diminishes.     

Conservative treatment of clavicular fractures

The outcome of 99 clavicular fractures was examined retrospectively through a questionnaire and, in 20 cases, clinical examination. Primary treatment was in all cases a simple sling or a figure of eight bandage. The aim of the study was to examine prognostic factors in relation to the end-result. The fractures were classified, according to the roentgenograms, and the primary dislocation, primary shortening and secondary shortening of the shoulder were recorded. The end-result was expressed as the degree of pain. Statistically significantly more patients with group two type two fractures had a poor result. No other prognostic factors were found.     

Results of 193 conservatively treated acute fractures of the carpal navicular--indications for operative treatment (author's transl)

The results of 193 conservatively treated acute fractures of the carpal navicular are presented. Ninety-eight (50.7%) had horizontal oblique fractures, 82 (42.5%) transverse, and 13 (6.8%) vertical oblique fractures. In 23 (11.9%) cases the fracture was located in the proximal third, in 125 (64.7%) in the middle third, and in 45 (23.4%) in the distal third. An unpadded cast extending from the elbow to the metacarpophalangeal joints including the thumb was used generally. On the following day the cast was always completed by addition of a volar plaster splint and a circular plaster bandage. Duration of immobilization lasted from 6 to 16 weeks (mean: 10 weeks). On average, 4.5 years after injury 190 (98.4%) fractures had healed by osseous union and 3 (1.6%) had a pseudarthrosis. The reasons for non-union were too short time of immobilization, and former diastasis between the fragments. The number of arthrosis in the radiocarpal joint in our patients amounted to less than 1%. Primary operative treatment (open reduction and screwing) is preferred for vertical oblique fractures and for fractures with a large diastasis between the fragments. Secondary operative treatment is performed if there are no signs of osseous consolidation.     

Bell's palsy (prevention and treatment)

The effectiveness of a variety of the most popular methods used for treatment Bell's paralysis is analyzed on a great number (1168 patients) of cases. It has been found that the results of the treatment are predetermined primarily by the gravity of the facial nerve affection. No convincing dependence of the treatment effect on the disease etiology was noted, except cases of Bell's paralysis of vascular etiology, the outcome of which was worse. A less favourable outcome was also observed in patients over 60 years of age and in cases of paralysis relapses. Of the methods of treating Bell's paralysis tested by the authors it was early use of perineural injections of hydrocortisone and novocaine in combination with the traditional methods (etiotropic, resorptive, and restorative means, electrotherapy, exercises) that proved to be the most efficacious. On the basis of the follow-up study of 676 patients recommendations on the treatment of residual phenomena of Bell's paralysis and on preventing the latter's relapses are given.     

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).     

Endoscopic treatment methods in patients with the postcholecystectomy syndrome

458 patients with postcholecystectomy syndrome have been examined. In 289 (63.1%) of them the reason of complication and location of the lesion in biliopancreatic-duodenal zone have been specified. In 212 (73.4%) patients the endoscopic treatment was used, including papillosphincterotomy with removal of concrements; suprapapillary choledochoduodenostomy; nasobiliary draining, endoprosthesis. In 181 (85.4%) of cases these methods appeared to be efficient and final; in 31 (14.6%) they promoted stabilization of clinical status of patients and performing surgery in more favorable conditions. Complications have been registered in 4 (1.9%) patients, 1 patient (0,47%) died. The authors advocate endoscopic methods as methods of choice in postcholecystectomy syndrome.     

Conservative or operative treatment of fractures of the head of the tibia (author's transl)

Whether fractures of the head of the tibia have to be treated conservatively or surgically in an active way depends on the type of the fracture. In cases with small dislocation conservative treatment should be given priority. Only fractures with badly dislocated fragments should be operated on (osteosythesis).     

Therapy of dislocated calcaneus joint fracture with the AO calcaneus plate

From August 1992 to March 1997, 66 patients with 71 displaced intraarticular calcaneal fractures were prospectively examined after an operative treatment using an extended lateral approach and the ASIF calcaneal plate followed by early functional postoperative treatment (mean follow-up 25 months, retrieval rate 96%). To classify the type of fracture and to verify the results of reduction and of retention CT scans in the coronal and transverse plane were performed pre- and postoperatively and on the day of assessment. The Zwipp Score was used for clinical evaluation. After fractures with 5 to 8 points according to the calcaneal fracture scale, 97% of the patients had an anatomical or near anatomical reduction of the posterior facet and the clinical outcome in 82% of the patients was graded as good or excellent. In 70% of patients with a fracture rated 9 to 10 points a good reduction was demonstrated and clinically there were 67% good or excellent results. But in the fractures with 11 to 12 points, despite 40% good reductions, the clinical outcome was graded as good in 10% of the patients only. However, if the post-operative displacement of the posterior facet was more than 2 mm no patient had a good result independent of the type of fracture. Due to restoration of the geometry of the most comminuted fracture types and the immediate partial weight bearing secondary soft tissue problems could be minimized without any loss of articular reduction. Anatomical reduction and stable internal fixation together with adequate physical therapy are apparently preconditions but not a guarantee for a good clinical result after displaced calcaneal fractures.     

Variable phenotype of familial adenomatous polyposis in pedigrees with 3'' mutation in the APC gene

Traumatic rupture of the corpus cavernosum is relatively frequent in the authors' experience. Based on the study of a series of 80 cases and a review of the literature, the authors analyse the diagnostic and therapeutic aspects and outcome of this disease. The patients in this series had a mean age of 30 years. Meticulous and intimate clinical interview demonstrated that the commonest mechanism is forced manipulation of the erect penis (68%). Clinical examination localized the site of the fracture (proximal: 57%, distal 43%). The fracture was unilateral (78 cases), rarely bilateral (2 cases) and associated with complete rupture of the urethra (1 case). Treatment was surgical in 79 patients. A distal semicircumferential incision was used in the case of bilateral rupture, distal rupture and associated urethral lesion (34 cases). A favourable course was observed in 86% of cases. However, 9 postoperative complications (12.5%) were observed (6 cases of fibrous plaques, 3 cases of chordee of the penis), due either to the extent of the haematoma or to the delay in treatment. Traumatic rupture of the corpus cavernosum is a disease of young adults, which requires early surgical treatment with an approach adapted to the type of lesions.     

Pelvic ring injuries

PURPOSE: Analysis of the trauma patient of fractures of the pelvic ring and classification according to AO/Tile. METHODS: 125 unselected patients (43 females, 82 males) were evaluated retrospectively by conventional x-ray, and CT examinations included follow-studies. RESULTS: Type-A fractures were seen in 36 (29%), Type-B fractures in 58 (46%), and Type-C fractures in 31 (25%) cases. Type-B and Type-C fractures mainly occurred in patients with traffic accidents and falls from great height. Type-A fractures were seen most often in patients with accidents at home or at work. However, in patients with complex fractures a classification concerning Type-B or Type-C fractures was difficult. SUMMARY: Based on CT criterias, in most patients a statement concerning the applied forces, the stability of the pelvic rim and the fracture type can be made.