Biomedical subjects
Publications and source records attributed to B D Browner.
We have each experienced a significant learning phase for surgical treatment of these fractures. However, problems of articular reduction remain significant, particularly for complex fractures. It is our opinion that a certain degree of centralization of acetabulum fracture treatment--especially for the associated types--can lead to an improved standard of care overall.
Fifty-four trauma patients with 61 femoral fractures stabilized within the first 24 hours of admission by closed antegrade Ender nailing were included in this study. This technique involves the insertion of Ender nails from a portal at the proximal end of the femur through the piriformis fossa. The curved distal ends of the nails were distributed throughout the distal femur to achieve greater purchase in the enlarged medullary canal of the distal fragment. This technique was used in one proximal, 20 midshaft, 37 distal, and three segmental fractures. There were 51 closed fractures, eight Grade I open, and two Grade II open fractures. The average age of the patient was 26 years, and the majority had polytrauma. The operative procedure was well tolerated by this group of patients. Pulmonary care was improved by avoidance of traction and enhanced capability for mobilization. Forty-two patients with 49 femoral fractures were available for complete follow-up. Forty-five fractures healed with the average time to appearance of bridging callus being 33 days, and average time to full union remodeled callus being 5.9 months. There were four nonunions, one delayed union, and eight malunions. There were nail protrusions in 22 cases (19 proximal and three distal). Fourteen patients required a second operation for reimpaction of the protruding nails or premature nail removal. These results were inferior to those obtained with the use of the retrograde Ender nailing technique or the Kuntscher nail. This technique should be used only if other techniques are unavailable or inappropriate, and only for stable, noncomminuted fractures.(ABSTRACT TRUNCATED AT 250 WORDS)
There have been many improvements made in external fixation, and fixators are being applied with renewed enthusiasm. Inspite of advances in design and application, complications related to the treatment of open fractures are still frequent. Although external fixation has dramatically improved the treatment of open fractures and made possible the salvage of previously amputated limbs, it is a complex technique with many pitfalls. These problems fall into two broad categories: those related to the application and maintenance of the pins and frame on one hand, and those related to the management of soft tissue and bony injuries on the other.
A case is presented in which the leg segments of MAS trousers were deflated without deflating the abdominal segment, causing the trousers to act as a venous tourniquet. As a result bleeding and edema secondary to a pertrochanteric hip fracture were aggravated, causing a compartment syndrome in the thigh; fasciotomy became necessary. MAS trousers must be inflated in proper sequence, the leg segments first and then the abdominal portion. In deflation, the order is reversed. Only if this sequence is followed can MAS trousers be used safely.
Judging the appropriate time for amputating lower extremities with open fractures and major soft tissue damage is a major problem for physicians. Limb salvage through vascular repair and external fixation is frequently unjustified. Attempts at saving a limb that should be amputated often are followed by renal failure, sepsis, and death. Much research remains to be done in this area.
The choice of treatment modalities for the fractured femur in the polytrauma patient is a continuing dilemma. Prevention and treatment of respiratory complications requires maximum patient mobility. Conventional traction methods restrict turning in bed and preclude moving the patient out of bed. Immediate open reduction results in additional blood loss, tissue trauma, and a higher rate of infection and nonunion. Immediate closed intramedullary nailing is an excellent method but requires special equipment and surgical expertise. To meet the mobilization requirements of good pulmonary care and avoid the problems of early open reduction, before the availability of immediate closed nailing, we adopted the use of modified Neufeld single-rope roller traction for the initial treatment of closed, Grade I open, and some Grade II open femur fractures. In 30 cases, the traction was used to maintain the fracture for 7 to 14 days preceding delayed internal fixation, while in another 22 cases of the traction was used as the definitive treatment modality in conjunction with case bracing. Sixty patients with femoral fractures were treated with this traction methods. Eight patients died, the other 52 were followed to fracture healing. There was one delayed union. There were no nonunions and no wound infections in either the internal fixation or continued traction groups. This traction system is an effective way to meet the needs of the polytrauma patient with a femur.
Massive trauma involving the foot was treated by external fixation in 33 cases and followed for 1 to 3 years. Amputations were performed in seven (21%) because of uncontrollable deep sepsis in two and massive injury in five. The other 26 (79%) had functionally acceptable feet at follow-up, but all had some stiffness and cosmetic deformity. Complications attributed to the Hoffman external fixation were limited to three pin tract infections. We recommend Hoffmann external fixation when it is necessary to: 1) stabilize major open fracture dislocations; 2) maintain length where bone is lost or extensively comminuted; 3) prevent soft tissue contractures; 4) control joint position for delayed ankle arthrodesis; and 5) provide easy access for soft and bone tissue reconstructions.
Functional residual capacity (FRC) was measured in 12 postoperative patients and in one preoperative patient before and after they received intermittent positive pressure breathing (IPPB) with room air for ten minutes at a peak delivered pressure of 15 cm H2O. Ten patients had a normal or low pretreatment FRC. After cessation of IPPB, the mean FRC decreased further. Arterial oxygen tensions, measured in 11 of the 13 patients, decreased in all 11 from a pretreatment mean of 67.8 +/- 4.3 mm Hg to an immediate posttreatment mean of 57.7 +/- 4.2 mm Hg. In five patients repeated arterial blood gases were measured. At 30 minutes, their arterial oxygen tensions had returned to the pre-IPPB values. This study demonstrates that the routine use of IPPB in postoperative patients accentuates preexisting hypoxia and, therefore, must be used with caution.
Cardiac output and pulmonary wedge pressure (PWP) were used to evaluate the end point of fluid resuscitation in 20 patients suffering from multiple trauma and shock. Eleven patients received crystalloid resuscitation and nine patients received colloid resuscitation. Fifteen of 20 patients had an adequate cardiac output at the termination of resuscitation, but but only six of these patients had a PWP above 10 mm Hg. There was no significant correlation between left ventricular stroke work index and PWP in these patients, either at the completion of resuscitation or during the following three days. Five patients did not achieve adequate cardiac output and four of these patients died, suggesting that cardiac output was the most important criterion for adequate resuscitation. If the goal of fluid resuscitation is to achieve an adequate cardiac output, then PWP was not a reliable guide. Furthermore, using both cardiac output and PWP as a guide to fluid resuscitation of our patients, we found that the type of fluid (crystalloid or colloid) for resuscitation did not influence the course of respiratory distress in these patients up to three days following resuscitation.