Small wire external fixation of high energy tibial plateau fractures

Open plate osteosynthesis for high energy tibial plateau fractures with dissociation between the metaphysis and diaphysis has been plagued with frequent soft tissue complications. The Harbor-University of California at Los Angeles Medical Center's experience with small wire external fixation supplemented by limited internal fixation is examined. This alternative method of adequate stable fixation offers the advantage of minimal soft tissue compromise. Twenty-four patients with Schatzker Type VI tibial fractures were treated with small wire external fixation. Supplementary limited internal fixation was used with percutaneous screws in 10 patients and with open reduction in one patient. Sixteen patients had isolated fractures, and eight others suffered multiple injuries. Minimum followup was 12 months. All fractures healed. Complications included one septic knee, two infections at screw sites, and one 10 degrees knee flexion contracture. One knee had Grade 3 radiographic arthrosis, five had Grade 2, 10 had Grade 1, and eight showed no arthrosis. The outcomes (Knee Society clinical rating system) of this study compare favorably with outcomes described in reports published previously for this type of fracture, despite inclusion of eight multiply injured patients. This technique preserves the goals of early range of motion and stable fixation for these devastating injuries, while decreasing the observed major wound complications and nonunion rates. However, longer followup may reveal higher arthrosis rates, specifically in those fractures that were not anatomically reduced.     

Doping of horses

Tobogganing is a very popular outdoor winter recreational activity. In order to elucidate the patterns of injuries associated with tobogganing all patients with an injury caused by falls from or collisions while on or being hit by a sled were sampled prospectively between the period of November 1996 and March 1997. 50 patients were included in this study, aged from 7 to 69 years (mean 25.5 years). Of these, 14 (= 28%) patients required admission to hospital lasting from 1 to 31 days (mean 13.5 days), 11 (22%) needed an operation. Over all we could register 55 injuries; the lower extremity was the region most commonly injured (63.6%), followed by upper extremity with 21.8%. The most common injury was the sprain of the knee. The most severe injuries could be found at the lower limb and at the vertebral column, including four fractures of the lower leg and 8 ankle-joint fractures as well as two fractures of the lumbar spine. The most common single procedure was the open reduction and internal fixation of a fibular fracture. In 48.6% of the cases the riders struck an object (tree, wall, post), while 32.4% fell from the toboggan caused by environmental conditions such as a bump or a ditch. The most important risk factor was an unadjusted speed referred to the environmental circumstances. Preventive strategies include tobogganing in adequate environmental conditions with no trees, no post or other stationary objects that could result in a collision. Speed should be adapted to the slope conditions.     

Injuries due to antipersonnel land mines in Sri Lanka

This series comprises 191 victims injured by antipersonnel land mines in the North-east of Sri Lanka. The pattern of mine injuries is described and the injuries to the lower limb are classified according to the level of injury. Injuries to the lower limb were the commonest and over 73% required a below knee amputation. Recommendations are made for the improved care of these victims. The socio-economic effects of mines experienced by other countries affected by internal conflicts are described. The preventive measures that could be taken to avert such a situation in Sri Lanka are stressed.     

Arthroscopic reduction and fixation of bony avulsion of the posterior cruciate ligament of the tibia

Bony avulsion fractures of the posterior cruciate ligament of the tibia have commonly been treated by open reduction and internal fixation using the posterior approach. However, this approach, using the prone position, makes it difficult to investigate and treat other combined injuries of the knee joint. We report a case of posterior cruciate ligament avulsion of the tibia that was arthroscopically reduced and firmly fixed with two cannulated screws. The posterior sag was absent after the operation and the result was excellent. By arthroscopy, we got rigid fixation of the avulsed fragment for early rehabilitation, and detection of a concomitant injury was also possible.     

Nonselective debridement and antimicrobial cleansing of a venting ductal breast carcinoma

Supracondylar femur fractures above a total knee replacement are rare injuries that may be challenging to treat. We present a case of an elderly woman whose supracondylar femur fracture was not deemed amenable to conventional treatment. This patient underwent fixation of her femur fracture above a total knee replacement using an Ilizarov external fixator. The fixator was removed at 10 weeks, at which time the fracture was solidly healed. At the most recent follow-up, the patient is 19 months postinjury. She is fully weight bearing without walking aids and has a knee range of motion of 0 degree to 110 degrees.     

Inline skating, an old sport, newly discovered: harmless or a potential danger with socioeconomic effects?]

Over a period of one year, all accidents associated with in-line skating (ILS) were surveyed. Sport-specific data was recorded with a standardized questionnaire. The study comprised 66 patients with 75 injuries (48 upper limb, 16 skull, eight lower limb, three trunk). We were looking after 42 male and 24 female patients with an average age of 20 years (5-53 years). Twenty-seven patients (40%) had to be treated as inpatients. Overall, the most frequent injury (one third of all injuries) was forearm fracture close to the wrist (21 radius fractures, four radioulnar fractures). It had to be reset in 20 cases. Additional internal fixation was required in 10 cases (Kirschner wire osteosynthesis, intramedullary nailing or plate osteosynthesis). Only five patients could be treated with plaster cast fixation alone. Most patients with injuries in the vicinity of the wrist were not wearing a wrist protector at the time of the accident. The most frequent reasons given for not wearing protectors was forgetfulness or the high price of protectors. However, there were also two distal radius fractures and a disc injury in the wrist in patients who had been wearing wrist protectors. In most cases, ILS accidents lead to appreciable damage requiring a healing period of several weeks to months (average period of loss of work 41 days). The bfu (advisory center for accident prevention) reckons with 60,000 ILS cases annually in Switzerland. These injuries are thus of great socioeconomic importance. In the future, better risk behavior must be achieved by informing the population (wearing protectors, especially for the wrist and head, attendance of training courses).     

Eye position effects on the neuronal activity of dorsal premotor cortex in the macaque monkey

Visual inputs to the brain are mapped in a retinocentric reference frame, but the motor system plans movements in a body-centered frame. This basic observation implies that the brain must transform target coordinates from one reference frame to another. Physiological studies revealed that the posterior parietal cortex may contribute a large part of such a transformation, but the question remains as to whether the premotor areas receive visual information, from the parietal cortex, readily coded in body-centered coordinates. To answer this question, we studied dorsal premotor cortex (PMd) neurons in two monkeys while they performed a conditional visuomotor task and maintained fixation at different gaze angles. Visual stimuli were presented on a video monitor, and the monkeys made limb movements on a panel of three touch pads located at the bottom of the monitor. A trial begins when the monkey puts its hand on the central pad. Then, later in the trial, a colored cue instructed a limb movement to the left touch pad if red or to the right one if green. The cues lasted for a variable delay, the instructed delay period, and their offset served as the go signal. The fixation spot was presented at the center of the screen or at one of four peripheral locations. Because the monkey's head was restrained, peripheral fixations caused a deviation of the eyes within the orbit, but for each fixation angle, the instructional cue was presented at nine locations with constant retinocentric coordinates. After the presentation of the instructional cue, 133 PMd cells displayed a phasic discharge (signal-related activity), 157 were tonically active during the instructed delay period (set-related or preparatory activity), and 104 were active after the go signal in relation to movement (movement-related activity). A large proportion of cells showed variations of the discharge rate in relation to limb movement direction, but only modest proportions were sensitive to the cue's location (signal, 43%; set, 34%; movement, 29%). More importantly, the activity of most neurons (signal, 74%; set, 79%; movement, 79%) varied significantly (analysis of variance, P < 0.05) with orbital eye position. A regression analysis showed that the neuronal activity varied linearly with eye position along the horizontal and vertical axes and can be approximated by a two-dimensional regression plane. These data provide evidence that eye position signals modulate the neuronal activity beyond sensory areas, including those involved in visually guided reaching limb movements. Further, they show that neuronal activity related to movement preparation and execution combines at least two directional parameters: arm movement direction and gaze direction in space. It is suggested that a substantial population of PMd cells codes limb movement direction in a head-centered reference frame.     

Injury of the popliteal artery & the popliteal branches: analysis of 31 consecutive cases

In complex traumas of lower limbs it is fundamental the reducing of the time of ischemia to reduce the number of failures in repairing surgery and the percentage of the demolishing of necessity surgery. The experience of the authors is based on 31 complex traumas of lower limbs with distal vascular injuries to Hunter's canal, which were associated to bone, nervous and muscular lesions. In total we are treated 37 vascular injuries by interposition of venous autografts in 37 cases, lateral pacth in one case ant suture T-T in two cases. The protection of the reconstructed vases, in case of a concomitant loss of substance, was entrused to microvascular flaps for 7 times latissimus dorsi, iliac crest and fascio-cutaneous for 5 times posterior reversed with distal baset and for three times antero-lateral, which in three cases of them needed successively a dermoepidermic grafts. The bone injuries, which were treated by external fixation, intramedullary nailing, plate and screws, just in two cases became worse in pseudoarthroses and just in one in osteomyelitis. The reparation of nervous injuries had bad results just in two cases. The percentage of saving of the limb it was about 83.9%.     

Peripheral arterial injuries: a reassessment

Ninety-four patients with peripheral arterial injuries were subjected to acute repair, negative exploration, or late repair of the complications of the arterial injury (false aneurysm, A-V fistula, and/or limb ischemia). The causes of failure after acute injury include extensive local soft tissue and bony damage, severe concomitant head, chest or abdominal wounding, stubborn reliance on negative arteriograms in patients with probable arterial injury, failure to repair simultaneous venous injuries, or harvesting of a vein graft from a severely damaged extremity. There is a positive correlation between non-operative expectant treatment and the incidence of late vascular complications requiring late arterial repair. Delayed complications of arterial injuries occurred most frequently in wounds below the elbow and knee.     

The management of war wounds involving bone

Over 200 high-velocity missile injuries treated in a low-technology environment were audited under the aegis of the International Committee of the Red Cross Hospitals in Afghanistan and Northern Kenya. Femoral fractures were treated either by traction or external fixation using a uniaxial frame. The results showed that patients treated by external fixation remained in hospital longer than those treated on traction. The positional outcome was identical in both groups. In tibial fractures the external fixator was only of extra benefit in those of the lower third when compared with simple plaster slabs unless more complex procedures such as flaps or vascular repair were to be performed. In complex humeral fractures, external fixation resulted in long stays in hospital and a large number of interventions when compared with simple treatment in a sling. We conclude therefore that in an environment where facilities are limited and surgeons have only general experience very careful initial wound excision is the most important factor determining outcome. The application of complex holding techniques was generally inappropriate.     

Spectrum of roller-blading injuries

We studied 32 patients who presented to the Accident and Emergency Department of Toa Payoh Hospital with injuries sustained while roller-blading (in-line roller skating). This sporting activity carries risk of injuries, often fractures, due to 3 principal mechanisms of injury. The first and main mechanism of injury is that of a forward fall with the arms outstretched as a protective gesture. This is associated with fractures of the distal radius in the majority of cases, although other injuries to the upper limb can occur. The second important mechanism is that of a backward fall with resulting injury to the back of the head. Lastly, the patient may fall sideways, often together with a twisting force to the lower limbs, resulting in ankle sprains and meniscus injuries to the knee. The vast majority of patients are young teenagers who are beginners and had not been properly clad in protective gear. Roller-blading therefore carries a very real risk of sporting injury.     

Retrograde intramedullary nailing of femoral diaphyseal fractures

OBJECTIVES: To prospectively evaluate the results of retrograde intramedullary nailing of femoral shaft fractures. DESIGN: Prospective, consecutive series. PATIENTS AND SETTING: All patients with a femoral shaft fracture admitted at an urban Level 1 trauma center from December 1995 to December 1996 were treated with a retrograde femoral intramedullary nail. INTERVENTION: Retrograde femoral intramedullary nailing was performed on a radiolucent operating room table. Through a three-centimeter medial parapatellar incision, a reamed ten-millimeter retrograde nail was inserted. METHODS: From the time of injury until union, the following parameters were assessed: operative time, blood loss, extent of comminution, open grade, associated injuries, Injury Severity Score, body mass index, time to union, secondary procedures, range of motion in the knee. and complications. RESULTS: Fifty-seven patients with sixty-one fractures were available for follow-up, which averaged 43.1 weeks. Fifty-two percent of fractures demonstrated Winquist Type 3 or 4 comminution. Twenty-six percent of the fractures were open. Fifty-two fractures healed after the initial nailing, five of seven dynamized nails healed, and one patient with bone loss requiring bone graft united yielding a final union rate of 95 percent. Of the three nonunions (5 percent), two healed with exchange nailing and one remains asymptomatic at seventy-one weeks. One patient developed a late septic knee that resolved with treatment. Excellent range of motion in the knee was obtained by those patients who did not have other ipsilateral limb injuries. CONCLUSIONS: This consecutive series had a 95 percent union rate after nailing and dynamization as necessary. No knee problems were associated with the retrograde femoral intramedullary nailing technique. The one septic knee raises concerns about the use of retrograde nailing in severe open femoral shaft fractures. Retrograde femoral nailing should be given serious consideration as an alternative to antegrade femoral nailing.     

Vascular injuries to the extremities

The treatment of vascular trauma is a challenging and increasingly successful endeavor. Improvement in patency rates and limb salvage have occurred through advances in diagnostic methods, materials for vessel replacement and techniques of repair. Several principals have evolved. An aggressive diagnostic approach is indicated with early arteriography in all suspicious injuries. Distal blood flow should be established as soon as possible. Associated venous injuries should be repaired if possible. Unstable orthopedic injuries shoud be stabilized conservatively with minimal internal wire fixation of fragments and the use of traction. Fasciotomy should be used in treatment of any injury involving prolonged ischemia of distal tissues.     

Fractures about the knee in children

The seriousness of the consequences of growth and angular disturbances about the knee that occur as a result of injuries in childhood cannot be overemphasized. The resulting limb length discrepancy is well known to the office practitioner, who sees these patients presenting with back problems during adulthood. Normal knee motion and stability are prime prerequisites for normal gait, and loss of knee motion as a determinant of gait can increase the energy requirement up to 300-fold. The management of these injuries presented has produced good results for the author. The author strongly recommends careful follow-up in metaphyseal fractures to guard against the development of angular deformities, the anatomical reduction of all intra-articular fractures, and x-ray examination of the hip in patients in the four to 15 year age group who have sustained minimal or insignificant trauma and who complain of pain about the knee.     

Treatment of tibial plateau fractures by limited internal fixation

Seventy-five adults who sustained 76 tibial plateau fractures were treated according to a prospective protocol using instability in extension as the principal indication for operative fixation. Patients showing instability underwent closed manipulative reduction under fluoroscopic guidance. If significant joint depression persisted after reduction, elevation of the fracture was performed either from below using bone punches through a cortical window or via limited arthrotomy. Iliac crest bone graft was used to buttress depressed fractures. Fixation was then secured using 7-mm cannulated screws with washers or buttress plates and screws. Postoperatively, 58 of 76 knees were managed in a hinged knee brace, allowing the patient early range of motion and protected weightbearing for 8 weeks. Patients who were found to have a stable knee were treated with Bledsoe braces according to the postoperative protocol. In the 75 patients, 18 of the 76 knees were unsuitable for percutaneous screw fixation because of fracture complexity requiring plates, severe open injuries, or inadequate reductions with limited fixation had been done. A minimum followup of 12 months was obtained in 55 patients (range, 12-59 months). All fractures had healed at the time of followup. Eighty-seven percent of the patients at followup had a successful outcome using Rasmussen's criteria. Fourteen of these patients had arthroscopic assisted reduction or evaluation. All seven patients who had poor outcomes had AO Type C3 fracture patterns. Severely depressed or comminuted fractures or fractures with significant metaphyseal diaphyseal extension may not be suitable for this technique and require the addition of an external fixation device or buttress plate to maintain the reduction and allow for early range of motion.     

Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage

OBJECTIVE: This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA: Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS: Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS: One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS: Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.     

Minimally invasive knee joint surgery

The treatment of knee joint injuries has seen a marked development. Arthroscopy is standard for diagnostic purposes, for meniscus resection and meniscus refixation. Anterior cruciate ligament reconstruction may be performed mini-invasive by arthroscopic or mini-open technique with comparable result. Drill guide systems and fixation techniques allow for precise and stable graft placement. Posterior cruciate ligament surgery is presently undergoing a similar process of optimisation as ACL surgery has some years ago. The surgical trauma of intraarticular fracture reconstruction was also reduced significantly. Retrograde nailing, percutaneous plating and specific exposures to distal femur and proximal tibia fractures have been established. Percutaneous osteosynthesis controlled by arthroscopy or fluoroscopy is widely used for B-fractures of the tibial plateau. Injectable bone mineral cement adds to reduced trauma of surgical treatment of these fractures. Mini-invasive knee surgery will develop rapidly in the coming years.     

Confirmed abuse cases in public residential facilities for persons with mental retardation: a multi-state study

Our experience with 10 patients who suffered midshaft fractures of the femur and injuries to their ipsilateral hips has resulted in a treatment protocol that we believe can avoid unnecessary complications. The surgical protocol is a three-stage procedure based on (1) intramedullary nailing of the femur with interlocking for preserving the anatomic length and rotation of the femur; (2) treatment of the hip joint injury by means of open reduction and internal fixation of the acetabular fracture and/or reduction and fixation of the fractured femoral neck; and (3) repair of the extensor mechanism. Eight patients received this treatment and had fast recoveries. Union of the femoral fracture and full range of motion of the knee joint were observed within 3 months. In contrast, two patients who had received different surgical treatment had incomplete functional recoveries. This study offers a treatment protocol for ipsilateral disruption of the extensor mechanism, hip joint injury, and midshaft fracture of the femur in the multiply injured patient that can achieve full recovery with no complications. This relatively rare combination of injuries is definitely worthy of special attention.     

Common rugby league injuries. Recommendations for treatment and preventative measures

Rugby league is the main professional team sport played in Eastern Australia. It is also very popular at a junior and amateur level. However, injuries are common because of the amount of body contact that occurs and the amount of running that is required to participate in the game. Injuries to the lower limbs account for over 50% of all injuries. The most common specific injuries are ankle lateral ligament tears, knee medial collateral and anterior cruciate ligament tears, groin musculotendinous tears, hamstring and calf muscle tears, and quadriceps muscle contusions. Head injuries are common and consist of varying degrees of concussion as well as lacerations and facial fractures. Serious head injury is rare. Some of the more common upper limb injuries are to the acromioclavicular and glenohumeral joints. Accurate diagnosis of these common injuries using appropriate history, examination and investigations is critical in organising a treatment and rehabilitation plan that will return the player to competition as soon as possible. An understanding of the mechanism of injury is also important in order to develop preventative strategies.