Biomedical subjects

A Poka

Publications and source records attributed to A Poka.

36 records · Page 2Linked to original sources

PubMed1988

Duration of preventive antibiotic administration for open extremity fractures.

The necessary duration of antibiotic administration after open fracture has not been established. In a double-blind prospective trial we randomized 248 patients with open fractures to receive one or five days of cefonicid sodium therapy or five days of cefamandole nafate therapy as part of the initial treatment. Rates of fracture-associated infections in the three groups were ten (13%) of 79, ten (12%) of 85, and 11 (13%) of 84, respectively. The 95% confidence limit for the difference in infection rates between the one-day group and the combined five-day groups was 0% to 8.3%. The actual difference was 0.2%. A brief course of antibiotic administration is not inferior to a prolonged course of antibiotics for prevention of postoperative fracture-site infections.

Adult↗

PubMed1988

Preoperative angiographic assessment of the superior gluteal artery in acetabular fractures requiring extensile surgical exposures.

Extensile exposures used for complex acetabular fracture reconstructive surgery often create abductor muscle flaps pedicled on the superior gluteal artery. Preoperative arteriograms were performed in eight patients who required extended iliofemoral or modified extended iliofemoral surgical approaches to assess the integrity of the superior gluteal artery. All of the patients had complex acetabular fractures, with significant displacement of the fracture into the sciatic notch. Abnormalities of the superior gluteal artery were found in three patients. One patient demonstrated a complete laceration of the superior gluteal artery, one patient a complete arterial occlusion, and one patient had a compressive entrapment of the artery at the fracture site. Preoperative angiographic evaluation of the superior gluteal artery is suggested for patients with acetabular fractures that are displaced into the sciatic notch and who will require an extensile surgical exposure creating an abductor muscle flap supplied by the superior gluteal artery.

Acetabulum↗

PubMed1988

Heterotopic ossification as a complication of acetabular fracture. Prophylaxis with low-dose irradiation.

In a retrospective review of thirty-seven patients who had operative treatment for thirty-eight complex acetabular fractures, postoperative low-dose irradiation was administered to seventeen patients (eighteen fractures) to suppress heterotopic ossification. All of the patients had been operated on through either an extended iliofemoral incision or a modified extended iliofemoral incision. The prophylactic radiation was administered using a low-dose protocol; most of the patients received 1,000 rads in 200-rad increments, starting on the third post-operative day. The incidence of heterotopic ossification in the eighteen irradiated limbs was much lower than in the twenty patients who comprised the control group (50 per cent compared with 90 per cent). Only two of the irradiated limbs had Class-3 heterotopic ossification as described by Brooker et al., and no patient had Class-4 (ankylosis of the hip). Of the twenty control-group patients, ten had severe heterotopic ossification: Class 3 in seven and Class 4 in three. The difference in the incidence of severe (Class-3 or 4) heterotopic ossification between the two groups of patients was significant (p less than 0.01).

Acetabulum↗

PubMed1988

Intramedullary nailing of femoral shaft fractures. Part I: Decision-making errors with interlocking fixation.

Dynamic intramedullary fixation depends on the configuration of the fracture for postoperative stability. Unanticipated loss of reduction of the fracture after dynamic intramedullary nailing of the femur may result from errors in surgical decision-making, specifically the failure to insert both proximal and distal interlocking screws. Of 133 dynamic femoral intramedullary nailings that were performed after interlocking techniques became routinely available, fourteen (10.5 per cent) were complicated by loss of postoperative fixation and reduction. Thirteen of the fourteen femora shortened an average of 2.0 centimeters; the remaining femur shortened slightly, with clinical loss of rotational stability. Eight of fourteen patients elected some form of surgical revision, most commonly closed osteoclasis with restoration of femoral length, followed by the insertion of a statically locked nail. Errors in surgical judgment were attributed to inadequate preoperative analysis of the pattern of the fracture; undetected intraoperative comminution during reaming or insertion of the nail, or both; or postoperative failure to recognize an increase in comminution and instability of the fracture. We suggest using high-quality preoperative radiographs to detect non-displaced comminution of the major fracture fragments. Any increase in comminution of the fracture that occurs with reaming of the canal or insertion of the nail is an indication for static interlocking fixation. Radiographs that are made immediately postoperatively should be analyzed while the patient is under anesthesia, and any previously undetected instability of the fracture should be treated by static interlocking fixation. Dynamic intramedullary stabilization of the femur should be reserved for transverse or short oblique fractures at the femoral isthmus that have type-I or type-II comminution.

Adolescent↗

PubMed1988

Intramedullary nailing of femoral shaft fractures. Part II: Fracture-healing with static interlocking fixation.

A consecutive, prospective series of ninety-seven patients who had 100 fractures of the femoral shaft that were treated with static interlocking nailing was analyzed to determine the incidence of union of the fracture without planned conversion from static to dynamic intramedullary fixation as a technique to stimulate healing of the fracture. Eighty-four patients (eighty-seven fractures) were studied through union of the fracture (average follow-up, fourteen months). Eighty-five (98 per cent) of the eighty-seven fractures healed with static interlocking fixation. Two patients needed conversion from static to dynamic interlocking fixation because of inadequate fracture-healing; both progressed to uneventful union. The time to full weight-bearing (average, eleven weeks) was individualized for each patient and depended on the cortical contact of the major fragments, the presence of bridging callus as seen on radiographs, and the extent of other injuries of the ipsilateral lower extremity. No deformation or failure of the static interlocking device developed after early walking with weight-bearing, but fatigue failure of one nail occurred in a non-ambulatory patient who had an intracranial injury. Pain related to soft-tissue irritation by the prominent heads of the interlocking screws, clinically presenting as bursitis or snapping of the iliotibial band, was severe enough in six patients to necessitate removal of either the proximal or the distal screw after union of the fracture. We concluded that static interlocking of intramedullary nails in femoral shaft fractures does not appreciably inhibit the process of healing of the fracture, and that routine conversion to dynamic intramedullary fixation, although occasionally necessary, need not be performed.

Adolescent↗

PubMed1988

A modified extensile exposure for the treatment of complex or malunited acetabular fractures.

A modification of the extended iliofemoral incision of Letournel and Judet facilitates the operative exposure of T-type, complex transverse, and both-column acetabular fractures and malunions. The modification includes the utilization of a T-shaped skin incision with large flaps, and osteotomies of the iliac crest, greater trochanter, and anterior superior iliac spine. The iliotibial band is transected and the abductor muscle mass is rotated posteriorly, hinged on the superior gluteal neurovascular bundle. Twenty patients had open reduction and internal fixation of a complex acetabular fracture using this surgical approach. Excellent surgical exposure allowed good or excellent reduction of the acetabulum in all patients. No flap necrosis developed, and all fractures healed. One non-union of a trochanteric osteotomy needed revision. This approach provides increased exposure of the posterior column and visualization of the entire surface of the joint and it allows fixation of the fracture from both sides of the iliac wing. The T-shaped skin incision allows utilization of a standard posterior approach with conversion to the extensile exposure if necessary. Options for late reconstruction are not compromised. Lagscrew fixation of the osteotomies allows aggressive rehabilitation of the joint.

Acetabulum↗

PubMed1987

Radiographic analysis of the Brooker-Wills interlocking nail in the treatment of comminuted femoral fractures.

Forty-three patients with 43 comminuted femoral shaft fractures treated with the Brooker-Wills interlocking nail were followed through bony union to determine the device's ability to maintain length and rotational control of these difficult injuries. Only severely comminuted fractures, types III and IV, were included. Implant complications were also studied. Average shortening for type III and type IV fractures measured 0.43 and 0.51 cm, respectively. Overall average shortening measured 0.47 cm (range, 0.0-2.2 cm). Maximal shortening occurred in a 72-year-old osteopenic female. Six of the 23 femurs stabilized with the smaller 13- and 14-mm-diameter nails shortened more than 1.0 cm, whereas lesser degrees of shortening tended to occur with larger-diameter implants. The proximal locking diagonal screw provided adequate proximal control and was never found to be the cause of fracture shortening. Rod deformation occurred in nine patients (21%) and was seen only in 13.0- and 14.0-mm-diameter rods. The distal lock was found to control rotation clinically but played only a minor role in preventing shortening. Distal shortening appeared to be controlled by bone-rod contact at the metaphysis, as nailings within 0.5 cm of the epiphyseal scar resulted in the least amount of shortening. Although this intramedullary device produced adequate clinical and radiographic results in comminuted femoral shaft fractures in the young, multiply injured patient, we caution against the use of the 13.0- and 14.0-mm implants. In addition, the efficacy of this implant is unproved in the osteopenic patient.

Adolescent↗

PubMed1987

Pedestrian tibial injuries.

From August 1980 through May 1984, 102 adult pedestrian patients with 130 tibial fractures were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. We reviewed their records for admission status, procedures performed, and results: 32 patients who died, underwent primary amputation, or were lost to followup were excluded, leaving 70 patients with 86 tibial fractures as the base study group. We grouped the data by year of admission and analyzed it in terms of the effects of changes in the treatment protocol on results, specifically the time to union. For the first year, the existing treatment protocol included: antibiotics, debridement and irrigation with a bulb syringe, stabilization according to wound size and surgeon preference, split-thickness skin graft, and bone grafting in response to delayed or nonunion. The average time to union for Grade III fractures was 58.39 weeks; average time overall was 53.95 weeks. In the fourth year, the altered treatment protocol included: antibiotics, debridement and jet lavage, scheduled rebridement, external fixation for open fractures, judicious use of open reduction/internal fixation for closed fractures, early free flap soft-tissue coverage, and early bone grafting by history and fracture pattern. The average time to union for Grade III fractures was 37.65 weeks; average time overall was 34.46 weeks. From the first to the fourth year, time to union for Grade III fractures decreased by 64.5% and time to union overall decreased by 63.9%. We feel the decrease is a direct result of early bone grafting, the fixator construct used, and judicious use of open reduction/internal fixation.

Accidents, Traffic↗

PubMed1987

Acute and definitive management of traumatic osteocutaneous defects of the lower extremity.

Twenty-two lower extremity osteocutaneous defects resulting from high-energy trauma were managed from the onset of injury to rehabilitation by a collaborative effort between orthopedic and plastic surgeons. Emergency debridement of devitalized soft tissue and bone, external fracture stabilization, and serial debridements prepared the wound for closure with predominantly free-muscle transfers performed an average of 17 days (range 3 to 43 days) after injury. Cancellous or vascularized fibula grafting, depending on defect size, was performed an average of 9 weeks (range 6 to 16 weeks) after muscle flap closure. In this group of patients, whose average injury severity score was 18 (range 9 to 45) and whose average segmental bone defect was 8 cm (range 3 to 18 cm), the average time after injury to full weight bearing was 61 weeks (range 39 to 120 weeks). The early infection rate was 14 percent. Two extremities were amputated. There have been no chronic infections. Follow-up has ranged from 9 to 34 months.

Adolescent↗

PubMed1987

Management of open grade III tibial fractures.

The successful management of grade III tibial injuries integrates an organized injury assessment schema, debridement, stabilization, and reconstruction protocols that assure maximal functional results.

Bone Nails↗

PubMed1987

Fractures of the femoral head.

Fractures of the femoral head infrequently accompany hip dislocations, but create complex therapeutic dilemmas for the orthopaedist when they do occur. The difficulties are compounded by existing incomplete classification schemes, which do not satisfactorily predict the final clinical results of a given injury or treatment. This chapter encompasses an extensive literature review of 238 published cases and analyzes the areas of confusion concerning this group of injuries. Our experience with 27 cases of femoral head fracture is presented. These examples emphasize the need for prompt, concentric reduction of the hip joint followed by individualized treatment of each type of femoral head fracture. An improved classification system to eliminate the ambiguities of previous systems and to provide the clinician with treatment guidelines for each type of femoral head fracture is proposed. These guidelines should improve the final results in these difficult and rare injuries.

Femur Head↗

PubMed1986

Lateral compression fractures of the pelvis: the importance of plain radiographs in the diagnosis and surgical management.

The management of pelvic fractures varies according to the nature of the disruptive force and hence the type of injury. Stabilization with compression devices or slings, which may be warranted in some injuries are contraindicated in lateral compression fractures due to the exacerbation of pelvic collapse they will induce. The diagnosis of this type of fracture is therefore of the utmost importance, and yet is frequently missed due largely to ignorance of this type of injury and its significance. Despite mention of this entity in surgical publications, there is a paucity of information in the radiologic literature, and no definitive radiologic appearances have been described. Forty-three patients with lateral compression fractures admitted to the Shock Trauma Unit of the University of Maryland were studied, and the radiologic features, together with diagnostic signs specific to this injury are presented.

Fracture Fixation↗

PubMed1986

Pelvic fractures: value of plain radiography in early assessment and management.

Assessment of pelvic fractures in severely traumatized, clinically unstable patients presents a diagnostic problem. Traditional plain-radiographic classifications of the fracture are of limited preoperative value to the surgeon who must apply corrective force in opposition to the original force vector causing the fracture. Computed tomographic scanning is an effective method of examining the pelvis but is time consuming and may be impractical in cases of severe injury. In a retrospective analysis of the plain radiographs of 142 cases of pelvic fracture, four patterns of force were identified, presenting distinctive, recognizable radiographic appearances. These patterns are anteroposterior compression, lateral compression, vertical shear, and a complex pattern. The resulting classification of pelvic fracture, based on radiographic and clinical findings, correlates with associated injury to soft-tissue structures and enables the surgeon to begin corrective procedures rapidly.

Biomechanical Phenomena↗

PubMed1986

Intramedullary stabilization of humeral shaft fractures in patients with multiple trauma.

Sixty-one patients with multiple injuries, which included sixty-three fractures of the humeral diaphysis, were treated by intramedullary stabilization of the fracture with Rush rods or Ender nails. Portals of entry allowing antegrade or retrograde insertion or insertion at the epicondyles were used. For most of the patients, closed intramedullary fixation of the fracture was performed within twenty-four hours of the injury. Adequate follow-up studies were obtained for fifty-six patients (fifty-eight fractures). Stabilization by antegrade insertion gave excellent results if the portal of entry did not violate the rotator cuff. Symptoms of impingement in the shoulder and pain associated with an incorrect position of the portal for antegrade insertion required early removal of the device. Each fracture that was treated with fixation through the epicondylar portal had a poor result, and this technique is not recommended. Retrograde insertion, with the portal of entry located proximal to the olecranon fossa, yielded excellent results. Care must be taken to prevent encroachment on the olecranon fossa, which can result in a block to extension of the elbow. The surgical technique of closed fixation by retrograde insertion is presented. Immediate closed intramedullary stabilization of the fractured humeral shaft resulted in a 94 per cent rate of union and a 62 per cent rate of excellent clinical results. This technique is particularly applicable to patients with multiple trauma, as it minimizes loss of blood and the risk to neurovascular structures while providing stability for mobilization and aggressive pulmonary physiotherapy. In our opinion, however, isolated fractures of the humeral shaft should be treated by non-operative methods.

Bone Nails↗

PubMed1986

Compartment syndrome in open tibial fractures.

A retrospective review of the cases of 180 patients who had 198 acute open fractures of the tibial shaft and were admitted to a multiple-trauma referral center over a three-year period revealed an incidence of accompanying compartment syndrome of 9.1 per cent (eighteen fractures in sixteen patients). Each of the eighteen compartment syndromes was documented by measurements of intracompartmental pressure that were obtained by the saline-injection technique, and all were treated by four-compartment fasciotomy. The incidence of compartment syndrome was found to be directly proportional to the degree of injury to soft tissue and bone; this complication occurred most often in association with a comminuted, grade-III open injury to a pedestrian. The physician must maintain a high index of suspicion to detect a compartment syndrome in the patient who has multiple trauma, as its clinical signs and symptoms may be masked by a closed injury of the head or the need for ventilatory support or prolonged anesthesia for other surgical procedures.

Accidents, Traffic↗

PubMed1984

Musculoskeletal trauma.

This article, written for emergency room physicians, provides simple, practical guidelines for the assessment and immediate treatment of musculoskeletal injuries of the multiply injured patient. The importance of the team approach and multidisciplinary management is stressed. An algorithm is provided to aid the emergency physician in performing the initial assessment and treatment in an organized fashion, with proper priorities given to musculoskeletal injuries. A systematic, anatomically oriented head-to-toe examination is suggested, performed in a cyclic fashion, correcting serious life- or limb-threatening pathology first. During the examination, special attention is required to support the cervical spine until there is radiologic evidence that the spine is stable. The emergency physician should remember that injuries that are not obvious during initial assessment may easily be missed unless the patient is re-examined in detail when the vital signs are stabilized. This is especially true in an unconscious patient with head or pelvic injuries or compartment syndromes. Guidelines are given for emergency treatment of dislocations, open fractures, and wounds because these may be the responsibility of the emergency room physician, depending upon local policies, availability of specialty staff, or constraints of time.

Emergencies↗

PubMedDate not supplied

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.

Adolescent↗

PubMedDate not supplied

Prospective comparison of retrograde and antegrade femoral intramedullary nailing.

OBJECTIVE: To prospectively compare the results, function, and complications of antegrade and retrograde femoral nailing for femoral shaft fractures. DESIGN: Prospective, randomized. SETTING: Urban Level 1 trauma center. PATIENTS: One hundred consecutive femoral shaft fractures. Fifty-four nails inserted retrograde and forty-six inserted antegrade. INTERVENTION: Ten-millimeter antegrade or retrograde nail inserted for a femoral shaft fracture after reaming. OUTCOME MEASUREMENTS: A comparison of the outcomes after antegrade and retrograde nailing of the femur. Data were collected for analysis on comminution, set-up and starting point times, open grade, location of fracture, injury severity score, body mass index, time to union, knee pain and motion, hip and thigh pain, and nail to intramedullary canal diameter difference. A linear regression model was employed. RESULTS: Knee motion was 120 degrees in all but one knee in each group. The antegrade nailed femurs healed faster than those treated retrograde (A = 14.4, R = 18.1 weeks, p = 0.0496). More patients required dynamization for union in the retrograde insertion group (17 percent versus 5 percent, p = 0.10, NS). In a linear regression model, a nail-to-canal-diameter difference and retrograde nailing had an association with an increased time to union. Knee pain was equal in both groups; however, thigh pain was higher in the antegrade group (p = 0.0108). All of the antegrade nailed femurs healed (100 percent), and 98 percent (one nonunion) of the retrograde femurs healed after secondary procedures. CONCLUSIONS: Both antegrade and retrograde nailing yielded high union rates. Each insertion technique has its own advantages and disadvantages. The two insertion modes appear to be relatively equal for the treatment of femoral shaft fractures.

Adult↗