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PubMed1989

[Grade III open fracture of the femoral diaphysis in a polytraumatized child].

Authors describe the case of a 7.5 years old girl run over and with polytrauma, whose bilateral fracture of the femoral diaphysis was treated with osteosynthesis. The operative indication was the III. degree open fracture on one side. Anatomical reduction was performed on both sides, with DC plate on the closed side and with fixateur externe after insertion of adaptation screws on the open one. The missing soft tissues were substituted with delayed split thickness mashgraft flaps. The injuries healed with good function. If the operative treatment of the femoral diaphysis is founded the lamellar osteosynthesis or the fixateur externe method is suggested.

Accidents, Traffic↗
PubMed1990

Lower infection rate after interlocking nailing in open fractures of femur and tibia.

Between 1975 and 1987 91 patients with Types I and II open lower extremity fractures (66 tibia and 25 femur) have been treated surgically with interlocking nailing at the I University Clinic of Traumatology, and the Trauma Department of Wilhelminenspital, Vienna. Our infection rate of 1.2% was found to be lower than figures cited in the literature. Conscientious indication of the interlocking nail in these circumstances cannot claim all the credit for these results, the appropriate preoperative management with preventive antibiotics together with excellent operative technique have to be taken into consideration as well. Reviewing these results, we have adopted the opinion that the interlocking nail, when selectively used in the hands of an expert, can be recommended not only in closed fractures but also in Types I and II open fractures of the femur and tibia, provided that the special principles of treatment in a particular case are not neglected.

Adolescent↗
PubMed1986

Immediate internal fixation of open fractures of the diaphysis of the forearm.

Between 1975 and 1983, fifty-seven patients were treated at Sunnybrook and Harborview Medical Centers with immediate internal plate fixation of an open diaphyseal fracture of the forearm. Fifty patients were available for follow-up, which ranged from one to nine years and averaged three years. The injuries were classified on the basis of the extent of soft-tissue injury as defined by Gustilo and Anderson, and consisted of twenty Type-I injuries, nineteen Type-II injuries, and eleven Type-III injuries. The complications included deep infection in two patients and non-union in six. The functional results were excellent or good in 85 per cent of the series. This study demonstrates that immediate stable plate fixation is a beneficial method of treatment of open fractures of the forearm. The results are related to the severity of the initial soft-tissue injury and the surgical technique. Autogenous cancellous bone-grafting at the time of closure of the wound in comminuted fractures in which interfragmental compression cannot be obtained is recommended.

Adolescent↗
PubMed1988

Immediate nailing of open fractures of the femoral shaft.

Débridement of the wound and immediate reamed nailing were performed on sixty-seven patients who had an open fracture of the femoral diaphysis. Forty-two of these patients were followed for a minimum of twelve months (average, twenty-three months). Using the classification system of Gustilo and Anderson, there were fifteen (36 per cent) Grade-I, nineteen (45 per cent) Grade-II, and eight (19 per cent) Grade-III soft-tissue injuries. All of the fractures healed within four months after injury. The average flexion of the knee was 127 degrees and that of the hip, 129 degrees. At least 90 degrees of flexion was achieved in both joints of all patients. Perioperative complications included loss of fixation in four patients (10 per cent), infection of the wound in two patients (5 per cent), a wound seroma in two patients (5 per cent), and thrombophlebitis in one patient (2 per cent). Late complications were angular malunion in three patients (7 per cent), limb-length discrepancy in three patients (7 per cent), external rotation malunion in one patient (2 per cent), and sciatic-nerve palsy in one patient (2 per cent). We concluded that immediate intramedullary nailing of an open femoral fracture can be accomplished safely, with an acceptable rate of complications, given thorough débridement of the wound, proper equipment, and an experienced surgical team.

Adolescent↗
PubMed1995

[Secondary plate osteosynthesis of open fractures of the lower extremity--still a therapeutic alternative!?].

During the time period from May 1, 1990 to July 31, 1993, a total of 102 tibial and 144 femur fractures were treated in the Department of Traumatology of the University of Bonn. 45 patients with 25 open tibial and 22 open femur fractures were treated according to a regimen including primary stabilization, usually in an external fixator, soft tissue reconstruction and delayed open reduction and internal fixation using an A0-plate. A majority of the patients were involved in motor vehicle accidents, leading to multiple injuries in 26 instances. The complication rate of 17% is comparable to the reports following intramedullary stabilization. Only three chronic infections, following one grade two open femur fracture, one grade two and one grade three open tibial fracture, were seen. Bony union was achieved after 24 weeks. It is shown that the use of the A0-plate in the treatment of open fractures of the femur and tibia offers not only logistic advantages but represents a viable alternative for the delayed stabilization of these injuries.

Adult↗
PubMed1996

Pyogenic arthritis of the hip following an occult open fracture of the pubic rami--a case report.

Most of the open pelvic fractures are associated with skin wounds of varying anatomy. Injuries of the pelvis, which only momentarily communicate with the exterior or into a hollow organ are often difficult to diagnose. We managed a patient with an occult open displaced fracture of the public rami that had probably torn the hip capsule and was not recognised on admission as the open wound was in the vaginal wall. It subsequently resulted in septic arthritis of the ipsilateral hip joint. Vaginal and rectal examination in grossly displaced pelvic fractures should be done to diagnose at an early stage any occult open wound which may pose high risk of contamination of the fracture site.

Adult↗
PubMed1992

The dynamic ASIF-BM tubular external fixator in the treatment of open fractures of the shaft of the tibia.

The dynamic ASIF-BM external fixator incorporates telescopic tubes for axial dynamization and angled bayonet screws to keep the tubes parallel to the bone axis, that is essential for gliding, and adjustment of rotation. The results after treatment of 70 type II and III open tibial fractures with static ASIF and dynamic ASIF-BM frames were analysed. Of the fractures, 32 were treated with the delta ASIF static frame, the other 38 with delta and uniplanar dynamic ASIF-BM frames. The groups were found to be comparable. The results of the study confirm that tubular external fixation is a safe method for treating the bone and soft tissue lesions in such fractures. The comparative study shows that axial compression, using the ASIF-BM device, with early weight bearing, gave a higher rate of union (97 per cent against 87 per cent with the ASIF frame), a shorter healing time (19 weeks against 29 weeks with the ASIF frame) and a decreased need for bone grafting (21 per cent against 84 per cent with the ASIF frame). The incidence of pin track infection was also decreased in dynamic frames. Thus it seems that the ASIF-BM dynamic fixator has a valuable part to play as a definitive mode of therapy for severe open fractures of the tibial shaft.

Adolescent↗
PubMed1990

[Pathophysiology of open fractures and principles of their treatment. Review].

Authors have worked out in detail the problems of fractures associated with the injury of soft tissues. They use their own classification dividing these fractures into two major groups, and namely open and closed fractures. In each group they distinguish 4 degrees of severity of the injury of soft tissues. Of decisive importance for both the final result and the course of the treatment is the method of treatment which starts already on the scene of the injury. The whole therapeutical management up to the actual operation has several successive phases. The way of osteosynthesis can be decided upon only after the primary treatment of the wound which makes it possible to evaluate properly the condition of soft tissues and the contamination of the wound. Of vital importance is the radicalism of the primary treatment and the removal of all necrotic tissues. Potential defects can be temporarily covered with artificial skin and permanently with skin grafts or muscular, myocutaneous or fasciocutaneous flaps.

Arm Injuries↗
PubMed1995

Open fractures of the femoral shaft, treated with osteosynthesis or temporary external fixation.

Controversy surrounds the treatment of open femoral shaft fractures, especially in the multiply injured. We report on 54 patients with 57 open femoral shaft fractures. They were treated according to our policy which deals with the severity of the soft-tissue damage. Low-grade open femoral fractures were primarily treated with internal fixation. A temporary external fixator was used for high-grade open fractures and in multiply injured patients where primary intramedullary nailing was contra-indicated. The external fixator was converted into an intramedullary nail as soon as the local soft-tissue disorders and the general condition of the patient permitted. There were no cases of deep infection. There was one case of malunion. Functional outcome was good to excellent in all cases. The aim of this paper is to show that low-grade open femoral fractures can be safely treated with primary intramedullary nailing and that temporary external fixation of severe open fractures followed by conversion into an intramedullary nail can be done without deep infection.

Adolescent↗
PubMed1988

[Open fractures of the elbow joint].

Both in open and in closed elbow fractures, anatomical joint reconstruction and rigid internal fixation, which permit early initiation of motion, are essential for good joint function. However, in open distal intraarticular humerus fractures this is more difficult to achieve, owing to the high rate of comminuted types C 2 and C 3 fractures. In addition, the extensive soft tissue lesions often mean that physiotherapy cannot be started until later than would otherwise be desirable. This retrospective study shows that the functional results in 60 patients operated on for correction of open distal intraarticular humerus fractures were worse (1/3 "excellent/good", 2/3 "moderate/poor") than those in patients treated for closed fractures. Complications included superficial infection in 7 patients, osteitis in 11, late instability in 10, fatigue failure of the implants in 5, and non-union in 10 patients.

Adolescent↗
PubMed1994

The role of intramedullary nailing in modern treatment of open fractures of the tibia and femur.

The increasing incidence of open tibial and femoral fractures causes great suffering by patients and is an enormous economic burden, necessitating improved treatment. The current treatment of these fractures is reviewed, as well as the evolving role of intramedullary nailing in this treatment. Intramedullary nailing seems to give better results than external fixation in Gustilo type I and II fractures, and is at least as good in type III. The introduction of the non-reamed interlocking intramedullary nail may bring about even better outcomes. Any improvements in treatment should be based on thorough understanding of the biology and biomechanics of the injury.

Bone Nails↗
PubMed1995

Pharmacokinetics of once-daily dosing of gentamicin in surgical intensive care unit patients with open fractures.

OBJECTIVE: To compare the first-dose pharmacokinetic parameters of gentamicin 6 mg/kg and 2 mg/kg in stable, nonobese surgical intensive care unit patients with open extremity fractures receiving gentamicin prophylactically. METHODS: Serial blood samples were obtained over 8 or 24 hours following the first dose of gentamicin. Serum concentrations of gentamicin were measured using fluorescence polarization immunoassay and analyzed by noncompartmental means. RESULTS: Eleven patients were enrolled, 7 in the 6 mg/kg group and 4 in the 2 mg/kg group. The median (6 vs. 2 mg/kg) age was 29 versus 28 years; serum creatinine 80 versus 88 mumol/L; and APACHE II score 13 versus 10. The mean +/- SD (micrograms/mL) of concentration at the end of the 30-minute infusion (Cmax), concentration 30 minutes after the end of the infusion (Cpk), and concentration at the end of the dosing interval for 6 versus 2 mg/kg were: 35.0 +/- 19.0 versus 10.1 +/- 1.77; 17.0 +/- 2.7 versus 5.4 +/- 0.4, and 0.45 +/- 0.31 versus 0.69 +/- 0.11, respectively. Area under the curve0-infinity (AUC0-infinity), apparent volume of distribution, and half-life were: 89.0 +/- 28.9 versus 26.1 +/- 1.2 mg.h/L, 0.40 +/- 0.10 versus 0.47 +/- 0.14 L/kg, and 4.0 +/- 1.1 versus 4.3 +/- 1.5 h, respectively. CONCLUSIONS: The first-dose pharmacokinetics of gentamicin 6 mg/kg resulted in a proportional rise in Cmax, Cpk, and AUC0-infinity compared with gentamicin 2 mg/kg in patients with open fractures, but with greater variability.

Adolescent↗
PubMed1976

[Prevention of suppuration in open fractures].

The authors have elaborated the complex of prophylactic measures against suppuration in treatment of open bone fractures, a special attention being given to the use of specific and nonspecific antistaphylococcic drugs: antibiotics of a wide spectrum of action, adsorbed staphylococcic anatoxin and staphyloccic polyvalent bacteriophage. Therapeutic measures and the results of their utilization are described.

Adolescent↗
PubMed2001

Treatment of open fractures of the shaft of the tibia.

We have systematically reviewed the effect of alternative methods of stabilisation of open tibial fractures on the rates of reoperation, and the secondary outcomes of nonunion, deep and superficial infection, failure of the implant and malunion by the analysis of 799 citations on the subject, identified from computerised databases. Although 68 proved to be potentially eligible, only eight met all criteria for inclusion. Three investigators independently graded the quality of each study and extracted the relevant data. One study (n = 56 patients) suggested that the use of external fixators significantly decreased the requirement for reoperation when compared with fixation with plates. The use of unreamed nails, compared with external fixators (five studies, n = 396 patients), reduced the risk of reoperation, malunion and superficial infection. Comparison of reamed with unreamed nails showed a reduced risk of reoperation (two studies, n = 132) with the reamed technique. An indirect comparison between reamed nails and external fixators also showed a reduced risk of reoperation (two studies) when using nails. We have identified compelling evidence that unreamed nails reduced the incidence of reoperations, superficial infections and malunions, when compared with external fixators. The relative merits of reamed versus unreamed nails in the treatment of open tibial fractures remain uncertain.

External Fixators↗
PubMed2003

[Calcaneus fractures. Open reduction and internal fixation].

AIM OF THIS STUDY: Critical analysis of the medium-term results of open reduction and internal fixation (ORIF) of displaced intra-articular calcaneus fractures with a standardized protocol in a greater patient cohort. METHODS: From October 1993 to December 1999 314 patients (mean age 42.3 years) with 348 calcaneus fractures were seen at the Dresden University Hospital. 41 fractures were open, 4 with 1st degree, 28 with 2nd and 9 with 3rd degree soft tissue damage. 275 displaced intra-articular fractures were treated with ORIF, 262 (95.3 %) with plate osteosynthesis via an extended lateral approach. 169 patients could be evaluated at a mean of 18 months (range 10-47 months) postoperatively with an extended protocol of questionnaire, physical and radiographic examination. RESULTS: The Maryland Foot Score after 18 months follow-up averaged 80.8/100, the mean Zwipp score averaged 146.4/200. The functional result with the Merle d'Aubigné score was judged good to excellent in 86% of cases. Rates of deep infection and superficial wound edge necrosis increased significantly with open fractures and delay in surgery of more than 2 weeks after injury in closed fractures. Clinical results were adversely affected by even minor residual steps in the posterior facet (1-2 mm) as judged by CT or Brodén views (p < 0.001). Böhler's tuberosity-joint-angle had an impact on the final result when falling short compared to the unaffected contralateral side by more than 30% (p < 0.001). CONCLUSIONS: Management of intra-articular calcaneus fractures with a standardized protocol of ORIF and early mobilization leads to reproducible good or excellent clinical results in a majority of patients. New approaches like an interlocking calcaneus plate, the use of subtalar arthroscopy, early soft tissue coverage for complex open injuries and percutaneous screw fixation for selected fractures should further improve prognosis.

Adult↗
PubMed1992

Open fractures of the tibia in children.

We describe the results of treatment of open tibial fractures in 92 children; 22 fractures were Gustilo type I, 51 type II and 19 type III. All children received tetanus prophylaxis, systemic antibiotics for 48 hours and thorough debridement and irrigation of the wound. Fifty-one wounds with minimal soft-tissue injury were closed primarily. The other 41 were initially left open; of these, 18 small wounds were allowed to heal secondarily and 23 larger wounds required split skin grafts or soft-tissue local or microvascular free flaps. Stable fractures were reduced and immobilised in an above-knee plaster cast (71%) and external fixation (28%) was used for unstable fractures, extensive soft-tissue injury and multiple injuries. Short-term complications included compartment syndrome (4%), superficial infection (8%), deep infection (3%), delayed union (16%), nonunion (7.5%) and malunion (6.5%): these incidences are similar to those reported in adults. Selective primary closure of wounds did not increase the incidence of infection. External fixation was associated with a greater occurrence of delayed and nonunion than plaster immobilisation, but this technique was used most often for the more severe injuries. Late review, at 1.5 to 9.8 years, showed a high incidence of continuing morbidity including pain at the healed fracture site (50%), restriction of sporting activity (23%), joint stiffness (23%), cosmetic defects (23%) and minor leg-length discrepancies (64%). Open tibial fractures in children are associated with a high incidence of early and late complications, which are more frequent in children with Gustilo type III injuries. The Gustilo classification was a useful guide for predicting the outcome and planning treatment.

Adolescent↗
PubMed2005

Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis.

The purpose of this study was to use multivariate analysis to evaluate contributing factors affecting deep infection and nonunion of open femoral fractures treated with locked intramedullary nailing (IMN). We examined 89 open femoral fractures (88 patients) treated with immediate or delayed locked IMN in static fashion at the Kitasato University Hospital from 1988 to 2001. Multiple regression models were derived to determine predictors of deep infection and nonunion. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type (I+II or III), fracture grade by AO type (A or B+C), fracture site (proximal site+distal site or middle site), timing or method of IMN, reamed or unreamed nailing (R versus UR), debridement time (< or =6 h or >6 h), existence of polytrauma (ISS<18 or ISS> or =18), and existence of floating knee injury (+ or -). The predictive variables of nonunion selected for analysis were the same as those for deep infection, with the addition of deep infection (+ or -). Five fractures (5.6%) developed deep infections: one Gustilo type II and four type III. Multivariate analysis revealed that only Gustilo type significantly correlated with occurrence of deep infection (p<0.05). Nonunion occurred in 12 fractures (14.1%). Multivariate analysis revealed that only fracture grade by AO type significantly correlated with occurrence of nonunion (p<0.02).

Adolescent↗
PubMed1995

Open fractures of the tibia in children.

The results of the treatment of open tibial fractures in 58 children aged between 3 and 15 years are reviewed. There were 25 Gustilo Type I, 22 Type II and 10 Type III fractures. At operation 37 wounds were closed primarily and 21 wounds were left open. Of these 21, 13 healed by secondary intention and eight required split skin grafting or soft tissue flap coverage. Stable fractures were immobilized in an above-knee plaster in 48 cases (83 per cent) and six fractures treated with external fixation (10 per cent). Two patients (3.5 per cent) had cast immobilization of the tibial fracture and traction for an ipsilateral femoral fracture. Two patients (3.5 per cent) with Gustilo Type IIIc injuries required an amputation, one 'de novo' as the limb was not salvageable and one 4 days after failed vascular reconstruction. All fractures healed primarily without bone grafting, although there were three cases of delayed union and seven cases of malunion. Six children had superficial wound infections but there were no cases of deep infection or osteomyelitis. There was one case of compartment syndrome.

Adolescent↗