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PubMed2000

A review of orthopedic injuries in three recent U.S. military conflicts.

We conducted a retrospective review of all patients with orthopedic injuries evacuated to a single medical center to evaluate the treatment and outcome of these injuries in three recent U.S. military conflicts: Operation Urgent Fury (Grenada), Operation Desert Shield/Storm (southwest Asia), and Operation Restore Hope (Somalia). Sixteen orthopedic casualties were originally treated at the medical detachment in Grenada before evacuation to the medical center. Most of these injuries were gunshot wounds to the extremities (11), with three known open fractures. Two patients (three extremities) sustained traumatic amputation (19% amputation rate). One hundred eighty-one patients with orthopedic injuries were medically evacuated from southeast Asia to the medical center for definitive treatment. Of these injuries, there were 143 fractures in 69 patients. One hundred of these fractures were open fractures, and 60% of these injuries were blast injuries. Furthermore, there were 26 amputations (14%). Twenty-two patients with orthopedic injuries were treated in Somalia and evacuated to the medical center. Thirteen of the 22 patients (59%) sustained gunshot wounds, and 2 (9%) sustained blast injuries. There were eight open fractures (36%) and three amputations in two patients (14%). Three of the 22 patients underwent successful limb salvage when ablation was the only other surgical alternative. It appears that a large percentage of medical center evacuations from military conflicts are for orthopedic injuries. Many of these injuries are the result of high-velocity weapons or blast injuries. Regardless of the size and/or purpose of the intervention, similar injury patterns and severity can be expected, because 51% of orthopedic patients had open fractures. Similarly, the rate of amputation associated with extremity trauma has not varied significantly since the Vietnam War.

Amputation, Surgical↗

PubMed2004

Antibiotics for preventing infection in open limb fractures.

BACKGROUND: Wound and bone infections are frequently associated with open fractures of the extremities and may add significantly to the resulting morbidity. The administration of antibiotics is routinely used in developed countries as an adjunct to a comprehensive management protocol that also includes irrigation, surgical debridement and stabilisation when indicated, and is thought to reduce the frequency of infections. OBJECTIVES: To quantify the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (April 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2003), MEDLINE (1966 to April 2003), EMBASE (1988 to April 2003), LILACS (1992 to June 2002) and reference lists of articles. Proceedings of meetings of the American Academy of Orthopaedic Surgeons (1980 to 2001), the Orthopaedic Trauma Association (1990 to 2001) and the Société Internationale de Chirurgie Orthopedique et Traumatologique (1980 to 2001) were hand searched. We also contacted published researchers in the field. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials involving: participants - people of any age with open fractures of the limbs; intervention - antibiotic administered before or at the time of primary treatment of the open fracture compared with placebo or no antibiotic; outcome measures - early wound infection, chronic drainage, acute or chronic osteomyelitis, delayed unions or non-unions, amputations and deaths. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened papers for inclusion, assessed trial quality using an eight item scale, and extracted data. Additional information was sought from three trialists. Pooled data are presented graphically. MAIN RESULTS: Data from 913 participants in seven studies were analysed. The use of antibiotics had a protective effect against early infection compared with no antibiotics or placebo (relative risk 0.41 (95% confidence interval (CI) 0.27 to 0.63); absolute risk reduction 0.08 (95% CI 0.04 to 0.12); NNT 13 (95% CI 8 to 25)). There were insufficient data in the included studies to evaluate other outcomes. REVIEWER'S CONCLUSIONS: Antibiotics reduce the incidence of early infections in open fractures of the limbs. Further placebo controlled randomised trials are unlikely to be justified in middle and high income countries. Further research is necessary to the determine the avoidable burden of morbidity in countries where antibiotics are not used routinely in the management of open fractures.

Antibiotic Prophylaxis↗

PubMed1992

Determining the prognosis for limb salvage in major vascular injuries with associated open tibial fractures.

Nineteen patients with open tibial fractures and associated arterial injuries were reviewed. Vascular injuries were documented by either arteriography (74%) or clinical examination and direct visualization of injuries intraoperatively. Arterial injuries were divided into those proximal to and those distal to the trifurcation. Proximal injuries involved the popliteal artery in all cases, whereas distal injuries involved the anterior tibial artery, posterior tibial artery, peroneal artery, or combinations of these arteries. All patients' limbs were initially considered salvageable. The eventual amputation rate was 58%. The Mangle Extremity Severity Scores ranged from 4 to 9, and Gustilo's open fracture classification system included 21% Type IIIB and 79% Type IIIC injuries. An isolated anterior tibial artery or peroneal artery injury had a good prognosis. A poor outcome was correlated with posterior tibial artery and popliteal artery injuries and injuries involving all three major distal trifurcation arteries simultaneously. These findings were statistically significant (P less than .05). Traditional criteria for primary amputation are reviewed, and the relevance of a varied prognosis with specific vascular injuries is discussed.

Adolescent↗

PubMed2001

Tangential views of the articular surface of the distal radius-aid to open reduction and internal fixation of fractures.

Open reduction and internal fixation of comminuted, displaced intra-articular or potentially unstable fractures of the distal radius with plate and screws has increasingly become a favoured treatment. Intra-operative assessment of fixation with the help of an image intensifier has always been difficult because of the anatomy of the distal radius. Imaging of the implants placed as distal as possible to achieve satisfactory fixation often shows the screws to be penetrating the joint. We describe two new radiographic views of the wrist joint, which we used intra-operatively in ten patients undergoing open reduction and internal fixation of distal radius fractures. Screws were thought to have been penetrating the joint in the standard lateral views of all of them and in the standard antero-posterior views of eight of them.However, no screw was seen penetrating the joint in these new views. It was hence possible to place the plate distal enough to enable the screws to engage the sub-chondral bone. We recommend the use of these views in the open reduction and internal fixation of distal radius fractures.

Bone Plates↗

PubMedDate not supplied

Analysis of fixation methods for vertical shear fractures of the medial malleolus.

OBJECTIVE: To evaluate 4 different fixation methods used to treat vertical shear fractures of the medial malleolus. METHODS: Eighty polyurethane models of the distal tibia were osteotomized in a reproducible manner to create a vertical shear fracture of the medial malleolus. Twenty specimens were then randomly assigned to 1 of 4 fixation groups. Two fixation groups used a neutralization plate, whereas 2 groups were screw-only constructs. Ten of the specimens in each group were then randomly assigned to undergo either offset axial or offset transverse loading. RESULTS: The construct using a neutralization plate with 2 screws in the distal fragment exhibited greater stiffness in offset axial loading compared with the screw-only constructs placed an equivalent distance from the tibial plafond. All specimens in the group with the properly applied neutralization plate exhibited elastic deformation, whereas the majority of the specimens in all other groups showed residual displacement or catastrophic failure of the construct. CONCLUSION: Fixation of vertical shear fractures of the medial malleolus with a properly applied neutralization plate offers a significant mechanical advantage over screw-only constructs.

Ankle Injuries↗

PubMed2005

Effectiveness of local antibiotic delivery with an osteoinductive and osteoconductive bone-graft substitute.

BACKGROUND: The morbidity associated with open fractures and open fracture treatment is well established. An osteoinductive and osteoconductive bone-graft substitute that prevents infection would decrease the number of procedures required to treat contaminated fractures by eliminating the need for surgical removal of cement beads and perhaps autograft harvest. We hypothesized that the combination of tobramycin-impregnated calcium sulfate pellets and demineralized bone matrix would prevent the establishment of infection in a contaminated fracture model. METHODS: A unicortical 12-mm-diameter defect was created in the proximal tibial metaphysis of twenty-nine Spanish goats. After contaminating the wounds with an infective dose of Staphylococcus aureus, we divided the animals into four groups. The negative control group received no treatment, the positive control group received tobramycin-impregnated polymethylmethacrylate beads, the demineralized bone matrix group received 2.5 mL of demineralized bone matrix, and the experimental group received tobramycin-impregnated calcium sulfate pellets with 2.5 mL of demineralized bone matrix. Radiographs were made and intraosseous tissue cultures were performed on postoperative day 21. RESULTS: The cultures showed no evidence of intramedullary infection in the experimental or the positive control group, but they were positive for Staphylococcus aureus in six of the seven goats in the negative control group and seven of the eight goats in the demineralized bone matrix group. CONCLUSIONS: The combination of tobramycin-impregnated calcium sulfate pellets and demineralized bone matrix was effective in preventing intramedullary Staphylococcus aureus infection in a contaminated goat fracture model.

Animals↗

PubMed2004

Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures.

The management of open tibial fractures is a challenge to all orthopaedic trauma surgeons. The major goals are fracture union, uncomplicated soft tissue healing and return to pre-injury level of function. The geographical isolation and vastness of the Northern Territory of Australia complicates the management of these injuries by adding a significant delay to treatment. Forty-five patients sustained 48 open tibial fractures over the 30-month period of the study. Twelve received primary surgical treatment within 6h of injury but 33 were treated more than 6h after injury. The mean time to treatment in this latter group was 12h 15min (median 9h 45min, range 6-37h). The majority of injuries were high energy, with 23 patients having multiple injuries and 29 fractures (60%) being classified as AO C3 with 35 (73%) having Gustilo III soft tissue injuries. There was a mean time to union of 7.5 months and an overall complication rate of 42.2%. Thirteen patients (29%) required additional (late) surgical procedures subsequent to definitive fracture and soft tissue management. The zone of injury infection rate was 12.5%. The high incidence of open tibial fractures places a large financial burden on the state. However, despite the absence of a plastic surgical service and delays in presentation, satisfactory outcomes can be obtained by the application of the established surgical principles of thorough debridement, soft tissue management and fracture stabilisation.

Adolescent↗

PubMed1996

Age as a prognostic factor in open tibial fractures in children.

Thirty-one consecutive open fractures of the tibia were reviewed prospectively. Duration from injury until last examination averaged 3.7 years. The patients were divided into 2 groups for comparison: Group A consisted of children younger than 12 years of age and Group B of patients 12 years of age or older. The fractures were graded according to the system of Gustilo and Anderson. The severity of patient injuries in each group was similar. The treatments were likewise similar, but for all parameters studied, the younger patients fared better than their older counterparts. This study suggests that open fractures in children younger than 12 years of age require less aggressive surgical treatment, heal faster, are more resistant to infection, and have fewer complications than those in older children.

Adolescent↗

PubMed1990

Primary or delayed closure for open tibial fractures.

Of 110 consecutive open tibial fractures 90 were reviewed and analysed retrospectively with particular reference to wound closure, method of stabilisation, infection rate and the incidence of non-union. There were 41% Gustilo type I, 39% type II and 20% type III injuries. The incidence of deep infection was 20% after primary wound closure compared with 3% after delayed closure, and eight of the nine non-unions followed primary closure. We conclude that primary wound closure should be avoided in the treatment of open tibial fractures.

Adult↗

PubMed1985

[Significance of fracture form and bone necrosis for the treatment of open tibial fracture].

In a retrospective analysis the author deals with 370 open fractures of the tibia which were administered from 1961 to 1980. Treatment by plate osteosynthesis proved to be superior to conservative management (13% wound infections, 11,3% aseptic complications). Special importance is attached to the degree of soft tissue damage as a cause of osteonecrosis in certain types of fractures. By presenting a new classification scheme of fractures of the tibia the author is able to derive that kind of treatment which is required.

Adult↗

PubMed1991

Our contribution to the external fixation in traumatology.

The experience is summarized in using the method of external fixation (Stuhler-Heise from Aesculap, Poldi 7, Ilizarov's compressory distractive devices) in the traumatology of extremities within 5-year lasting period. Starting from june 1985 to July 1990, the amount of 90 open fractures of long bones has been managed (10.2% of all fractures admitted). Open fractures related to III. grade by Gustilo's classification were 20 in number, i.e. 22.0% of all open fractures admitted with anatomical distribution as follows: 50% crural, 25% humeral, 15% forearm and 10% femoral locations. The EF device was applied in 11 cases, i.e. 55%. Primary amputations were done in 4 cases, i.e. 20%. The EF application period averaged for 64 days. One case showed primary healing of EF treated fractures. The remaining cases attributed an exchange of the type of osteosynthesis or were supplemented with plastic surgery on the soft tissues and bone. Another group of 36 pseudoarthroses of long bones were operated on within the mentioned period, from them 9 cases as infected ones were treated with EF method. Once the infection has been healed, the authors proceeded with surgery and EF exchange in all cases when treating pseudoarthroses. Third--the group of 18 nonstabile intraarticular fractures of distal radius treated by means of EF is presented. The advantages of individual EF methods are discussed, and the comprehensive care approaches are presented in documental groups of injuries as illustrated with the short case-reports.

External Fixators↗

PubMed2002

The treatment of open tibial fractures and of tibial non-union with a novel external fixator.

We report the results of external fixation in 29 patients treated for tibial fractures and tibial non-union using a novel multi axial external fixator (MAXX) followed prospectively until bony union. The results of treatment were classified according to the Association for the Study and Application of the Method of Ilizarov (ASAMI). Overall, 13 patients had excellent bone results; 13 had good bone results; two had fair bone results, and 1 patient had poor bone results. Regarding functional results, 21 patients had excellent results; 6 obtained good results; none had fair results, and two had poor results. Acute patients did better functionally than chronic patients. This fixator is safe and versatile, although the indications for its use are very specific.

Adolescent↗

PubMed2002