Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.
(41/1343)
We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure. (+info)
Late fracture of the hip after reamed intramedullary nailing of the femur.
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In a consecutive series of 498 patients with 528 fractures of the femur treated by conventional interlocking intramedullary nailing, 14 fractures of the femoral neck (2.7%) occurred in 13 patients. The fracture of the hip was not apparent either before operation or on the immediate postoperative radiographs. It was diagnosed in the first two weeks after operation in three patients and after three months in the remainder. Age over 60 years at the time of the femoral fracture and female gender were significantly predictive of hip fracture on bivariate logistic regression analysis, but on multivariate analysis only the location of the original fracture in the proximal third of the femur (p = 0.0022, odds ratio = 6.96, 95% CI 2.01 to 24.14), low-energy transfer (p = 0.0264, odds ratio = 15.56, 95% CI 1.38 to 75.48) and the severity of osteopenia on radiographs (p = 0.0128, odds ratio = 7.55, 95% CI 1.54 to 37.07) were significant independent predictors of later fracture. Five of the 19 women aged over 60 years, who sustained an osteoporotic proximal diaphyseal fracture of the femur during a simple fall, subsequently developed a fracture of the neck. Eleven of the hip fractures were displaced and intracapsular and, in view of the advanced age of most of these patients, were usually treated by replacement arthroplasty. Reduction and internal fixation was used to treat the remaining three intertrochanteric fractures. Three patients developed complications requiring further surgery; five died within two years of their fracture. (+info)
CT-guided internal fixation of a hangman's fracture.
(43/1343)
Most hangman's fractures are treated conservatively. If surgery is indicated, an anterior approach using a C2/C3 graft and plate fusion is usually preferred. Another surgical method according to Judet is direct transpedicular osteosynthesis by the dorsal approach. This surgery is frequently rejected because of the high risk of spinal cord damage or vertebral artery tear. Direct transpedicular osteosynthesis of hangman's fracture according to Judet is a "physiological operation" that does not cause fusion and creates anatomical conditions. This procedure enables appropriate reduction, compression of fragments and immediate stabilization of the C2 segment. A new aspect of Judet's method of internal fixation of a hangman's fracture is now proposed. Computed tomographic (CT) guidance is used to ensure safe and exact introduction of two screws from the posterior approach. This method of CT-guided internal fixation of hangman's fracture allows, preoperatively, for an accurate assessment of the pattern and course of fracture line, selection of the anatomically safest screw path and determination of an appropriate screw length. The procedure also allows for accurate intraoperative control of instrument and implant placement, screw tightening, fracture reduction and anchoring of the screw tip in the contralateral cortex, using repeated CT scans. The procedure is performed in a CT unit under sterile conditions. This method was used in the treatment of eight male and two female patients aged 21-71 years. All treated patients were without neurological deficit. Follow-up ranged from 12 to 57 months (mean 33.3 months). No intraoperative or early or late postoperative complications were apparent. This new aspect of the surgical procedure ensures highly accurate screw placement and minimal risks, and fully achieves the "physiological" internal fixation. (+info)
A simplified Galveston technique for the stabilisation of pathological fractures of the sacrum.
(44/1343)
Mechanical stabilisation of pathological fractures of the sacrum is technically challenging. There is often inadequate purchase in the sacrum, and stabilisation has to be achieved between the lumbar vertebrae and ilium. We present a simplification of the Galveston technique. We treated a total of six patients with this technique, four for metastatic disease and two for primary tumours. Our technique consists of the formation of a proximal stable construct using ISOLA pedicle screws linked distally using a modular system of connectors to threaded iliac bolts with cross linkages. Neurological decompression and fusion was performed as appropriate. The benefits of this method are: ease of access to the ilium, a solid purchase to the ilium, less rod contouring and shorter operating time. We have had no operative complications from this procedure. All patients were discharged home mobile, with a reduced opiate requirement. (+info)
Displaced supracondylar fractures of the humerus in children.
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We performed an outcome study of completely displaced supracondylar fractures in children in order to assess the outcome of primary open reduction and internal fixation for these injuries. A total of 16 patients (mean age of 5.9 years) were included in the study. The mean follow-up was 2.6 years and patients were assessed after fracture healing using the criteria of Flynn et al. and Mark et al. Thirteen patients had an excellent result, two had good results with less than 10 degrees loss of carrying angle and one had a fair result based on degree of loss of elbow flexion. Open reduction and internal fixation of these fractures is an effective and safe method of primary treatment and is associated with good outcomes. We recommend a low threshold of proceeding to open treatment in these serious injuries. (+info)
Self-surgery: removal of ankle surgical implants--A case report.
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Self-surgery is rare, but numerous cases of self-mutilation are reported in the literature (eg, castration, enucleation of an eye, and amputation of a limb).[1] We have found no previous reports in the literature of a patient who has performed self-surgery to remove fracture fixation implants. (+info)
Rigid internal fixation of fractures of the proximal humerus in older patients.
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In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 +/- 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus. (+info)
Traumatic invagination of the fourth and fifth cervical laminae with acute hemiparesis.
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We describe a patient with traumatic right-sided invagination of two consecutive laminae into the spinal canal. The injury resembled a greenstick fracture and resulted in an acute Brown-Sequard syndrome. There was also an undisplaced hangman's fracture of the axis vertebra. These injuries were caused by an acute hyperextension and axial compression of the cervical spine. Open reduction and internal fixation of the laminar fractures without fusion was followed by full neurological recovery within six weeks. (+info)