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PubMed1999

Deep infection and fracture healing in immediate and delayed locked intramedullary nailing for open femoral fractures.

Fifty-nine patients with 61 open femoral fractures were treated with immediate locked intramedullary (IM) nailing (group 1; n=15), delayed IM nailing following nonoperative treatment (group 2; n=42), and delayed IM nailing following external fixation (group 3; n=7). Sixteen fractures were Gustilo type I, 28 were type II, 7 were type IIIA, 6 were type IIIB, and 4 were type IIIC open fractures. Four (6.6%) deep infections occurred. Significant differences existed in the deep infection rate (DIR) between types I and II and all type III fractures (2.3% for types I and II versus 17.6% for type III). The deep infection rate did not differ significantly among the nailing groups (13.3%, 2.6%, and 15.3% for groups 1, 2, and 3, respectively), nor did the deep infection rate correlate with the degree of fracture comminution, the existence of polytrauma or polyskeletal trauma, or preexistence of superficial or pin-site infections. Seven (11.7%) of these fractures resulted in nonunion, excluding one secondary amputation; the nonunion rate correlated with fracture location. There were no significant differences in the mean fracture healing times between any of the nailing groups. These results suggest that IM nailing for the treatment of type III open femoral fractures should be considered carefully, regardless of whether it is performed immediately or delayed.

Adolescent↗
PubMed1998

Is colostomy always necessary in the treatment of open pelvic fractures?

BACKGROUND: Wound management in open pelvic fractures has used fecal diversion, debridement, and closure by secondary intention to prevent pelvic sepsis. Colostomy care and takedown adds to the morbidity and resource utilization of this approach. We reviewed our experience to determine if a selective approach to fecal diversion based on wound location was possible. METHODS: Retrospective analysis of patients admitted to a Level I trauma center during an 8-year period. Fractures were classified as open if the fracture was in continuity with the wound. Wounds were classified as perineal if they involved the rectum, ischiorectal fossa, or genitalia, and as nonperineal if they involved the pubis anteriorly, iliac crest, or anterior thigh. Pelvic sepsis was defined as cellulitis, fasciitis, or infection of a pelvic hematoma. Diversion consisted of loop or end colostomy. RESULTS: Eighteen patients with open fractures were identified. Four died from closed head injury and blood loss. The remaining 14 were treated as follows. Five patients with perineal wounds had diversion of their fecal stream. Their Injury Severity Score was 34 +/- 8.3 and their Revised Trauma Score was 7.69 +/- 0.15. No patient developed pelvic sepsis. Nine patients with nonperineal wounds did not undergo diversion. Their Injury Severity Score was 28.6 +/- 5.3 and their Revised Trauma Score was 7.36 +/- 0.45. No patients developed pelvic sepsis in the nondiverted group. CONCLUSION: No patients with anterior wounds and an intact fecal stream developed pelvic sepsis. Colostomy may not be necessary in all patients with open pelvic fracture. Protocols using fecal diversion based on wound location appear to be safe and may decrease resource utilization and subsequent morbidity related to colostomy closure.

Adult↗
PubMed1991

Open reduction and internal fixation of radial head fractures.

Open reduction and internal fixation of displaced fractures of the radial head were reviewed in 14 elbows. Follow-up averaged 32 months. The average elbow score for Mason type II fractures was 96.8 points, corresponding to 100% good or excellent results. Average flexion was 142.5 degrees, and the mean fixed flexion deformity was 3.9 degrees. There was no loss in grip strength. An almost normal elbow was the expected result. Good or excellent results were achieved in only 33% of Mason type III fractures treated with open reduction and internal fixation. The average elbow score was 72.9 points, and this was statistically significantly different than the Mason type II fractures (p less than 0.05). An associated elbow dislocation did not affect the results significantly, but was associated with a slightly increased fixed flexion deformity. Fractures may be more comminuted than suggested by plain radiographs, and intraoperative decision making is required in deciding between reconstruction or excision of the radial head. Excellent results were obtained provided an anatomical reduction with stable fixation and early range of motion were achieved. If a stable anatomic reduction cannot be obtained, then alternative treatment methods should be considered.

Adult↗
PubMed1991

Open hand fractures: prognosis and classification.

Two hundred open fractures distal to the carpus in one hundred twenty-one patients were studied retrospectively. One hundred seventy-three fractures were followed-up to complete bony union, which occurred at a median period of seven weeks. Ninety-seven total complications included nine wound infections in seven patients, eighteen malunions, seventeen delayed or nonunions, twenty-three fixation problems, and two late amputations. Infection rate increased in the presence of wound contamination, delay in treatment greater than twenty-four hours, or systemic illness. It was not increased by presence of internal fixation, immediate wound closure, large wound size, tendon/nerve/vascular injury, or high-energy mechanism. We suggest a classification predictive of infection: type I: Clean wound and no systemic illness; type II: Contaminated wound, delay in treatment greater than twenty-four hours, or significant systemic illness. We recommend choosing fracture stabilization on the basis of the mechanical needs of the fracture, regardless of wound size, injury energy, or contamination. Immediate wound closure is appropriate for type I injuries and delayed closure should be reserved for type II wounds.

Adolescent↗
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↗
PubMed1977

Non-union in open tibial fractures.

This is a retrospective study of 104 open fractures of the tibial shaft seen at a civilian teaching center. Seventy-one per cent of the fractures resulted from vehicular accidents. Twenty-seven per cent of the fractures did not unite and half of these non-unions were infected. Virtually all of the ununited tibial fractures were associated with fractures of the fibula and with extensive avulsions of skin and dirty wounds. Although a variety of techniques for care of the wound and treatment of the fracture was used, none was entirely successful. Some failures were attributable to inadequacies of wound care--either premature primary closure or failure to perform secondary skin closure. Other failures of treatment were associated with use of internal fixation. Early weight-bearing without internal fixation, however, did not uniformly result in union.

Accidents, Traffic↗
PubMed2005

Open calcaneal fractures: assessment and management.

Open calcaneal fractures are obscure fractures. Typically, these injuries result in a high-energy, polytraumatized patient population. Initial management consists of irrigation and debridement. Secondary forms of management continue to evolve. High-energy fracture subtypes and severe soft tissue injuries portend an unsatisfactory outcome, despite appropriate management. Standards for the type and timing of treatment have not been established.

Calcaneus↗
PubMed1980

Management of complex open tibial fractures with external skeletal fixation and early myoplasty or myocutaneous coverage.

The management of severe open fractures is difficult. The high energy forces cause considerable comminution, displacement and extensive soft tissue damage with associated skin loss, all of which complicate treatment. The authors review the role of the soft tissues in the healing process of complex, open fractures with special emphasis on the concept of the "open fracture wound". A surgey of the published results of the treatment of severe open tibial fractures provides the background for an approach to the management of these severe fractures by stable external fixation with early myoplasty or myocutaneous coverage; this is a departure from traditional orthopedic methods of treatment. The authors present their prospective treatment protocol and review the results in the first eight patients managed by this method.

Dermatologic Surgical Procedures↗
PubMed1986

Financial charges of hospitalized motorcyclists at the Massachusetts General Hospital.

We studied 47 hospitalized motorcyclists admitted through the Massachusetts General Hospital emergency room during a 1-year period. Four factors were studied: 1) hospitalization charges, 2) hospitalization lengths, 3) medical insurance profiles, and 4) patterns of injuries. The mean hospitalization charges were +15,114. The total hospital charges for this group of patients were nearly +700,000. These figures excluded the costs of subsequent admissions, surgeons' fees, rehabilitation, vocational training, legal suits, and loss of wages. Sixteen per cent of the charges were uncollectable. Forty-six per cent of the patients were uninsured. The average hospitalization was 22 days. The mean age was 22 years and 90% of patients were less than 30 years old. Eighty-five per cent of the patients sustained at least one fracture. Lower extremity fractures occurred in 60%, open fractures in 55%, and tibia fractures occurred in 33% of the patients. Associated head, chest, or abdominal injuries occurred in 40% of the patients. Patients with multiple fractures, open fractures, and grade 3 open tibia fractures had substantially higher hospital bills.

Accidents, Traffic↗
PubMed1993

[Open joint fractures of the distal lower leg].

Ninety-five open fractures of the joint at the distal end of the lower leg (73 ankle fractures, 22 fractures of the pylon tibia) were treated between 1970 and 1987. For different reasons (death, amputation, etc.) only 63 could be followed up. The clinical and radiological assessments of 60 patients are presented in this paper. The Weber evaluation (only 18% good-to-excellent results) seemed to be inadequate for grading these cases. Fifty-six percent of the patients rated the results as very good, 37% as good. Radiological signs of post-traumatic arthritis were found in 48% of the cases. Different arthritis rates were found in a subgroup followed up after 1.5 to 6 years, and another subgroup treated earlier (maximum 18 years). In the first subgroup post-traumatic arthritis was found in 20%; in the second group-treated more than 6 years ago-it was 79%. The fact that the outcome of these late results was worse may be because of the severe traumatization 6-18 years ago, but it is more likely that the results were better in the other subgroup as a result of improved procedures. Nowadays a broad-spectrum cephalosporin is administered in the emergency room. All open fractures are operated on as emergency cases as quickly as possible. All bandages applied at the accident site are removed in the operation theater, not before. There the wounds are carefully irrigated and debrided. Rigid internal fixation with a minimum apparatus is applied. Exceptions are made in the case of severe trauma: external fixation is applied to bridge the joint in the correct position.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

The contribution of open extremity fractures to infection in multiply injured patients.

We sought to determine whether a contaminated open fracture was a reliable component for calculating the Outcome Predictive Score in patients with multiple injuries. We studied 41 patients whose primary source of contamination was open extremity fractures. Only one of the 41 patients developed osteomyelitis. The rate of infection from an open fracture is minimal in the multiply injured patient. Inclusion of patients with open fractures in studies that assess the likelihood of infection and the value of anti-infective agents incorrectly identified patients for clinical trials and results in an overestimation of survival based on the Outcome Predictive Score. These findings suggest that open fractures should be excluded as an entry criterion in future clinical trials.

Bacterial Infections↗
PubMedDate not supplied

Mandibular reconstruction: open reduction and internal fixation of mandibular fractures.

Open reduction and internal fixation of mandibular fractures by intraosseous wiring in conjunction with intermaxillary fixation remains the mainstay of mandibular fracture treatment despite the availability of newer methods. The principles of treatment are reviewed, including indications for use of this technique and its advantages and disadvantages. Various surgical techniques are also reviewed and key points in their application emphasized.

Adult↗
PubMed1995

[External fixation in fractures of the lower limb in children].

PURPOSE OF THE STUDY: The indications, morbidity and results of the use of external fixation for fractures of the lower limbs in children is presented. MATERIAL AND METHOD: We studied 72 fractures of the lower limbs (femur: 25; tibia: 47) in 63 children over a seventeen year period. Average age at fracture was 10 yrs 6 mos. (range 4 yrs 5 mos to 14 yrs 6 mos). Forty fractures were open fractures. The indication for external fixation was decided in three different situations: 39 isolated fractures, 11 patients with multiple fractures, and 13 polytraumatized patients. Three different devices were used: Illizarov: 4, Judet: 16, Orthofix: 52. The fixators were left in place until fracture union was demonstrable. RESULTS: Final results were classed into three groups: good, good following reoperation and sequelae. Comparison of the three different series was made using Student's T test. 9 axial deviations or malrotations occurred: 6 times correction was possible with the device in place. Three cases of osteomyelitis occurred at the fracture site. 23 pin tract infections occurred (23 per cent) 5 of which were persistent and 4 required reoperation. The average healing time was different in the three groups: 4.5 mos for isolated fractures: 8.1 mos for multiple fractures and 5.7 mos for polytraumatized patients. Reoperation was required for 4 patients: 2 bone grafts, 1 decortication, 1 bone transport. Ten refractures occurred following removal of the device, 8 times in patients presenting multiple injuries. In 46 patients with a follow-up greater than 18 months, 9 presented an overgrowth between 1 and 2 cm. Following an average follow-up of 2 years 4 months, 7 patients presented sequelae, 56 had good results, 18 following reoperation. DISCUSSION: The use of external fixation remains an irreplaceable method for osteosynthesis of open fractures with severe soft tissue injuries, multiple fractures or in the polytraumatized patient. Some disadvantages such as pin tract infections and refracture following device removal should be taken into consideration before using it for the treatment of simple, isolated closed fractures of the lower limbs in children. CONCLUSION: When external fixation is chosen for treating fractures, it is preferable to use a modular device which allows axial corrections. Local pin site care is essential to prevent early infection. Early weight bearing and dynamization as soon as possible will promote callus mineralization, removal of the device must be progressive and cast protection is recommended.

Adolescent↗
PubMed1983

External skeletal fixation in children's fractures.

Fourteen children with acute fractures, mostly open fractures, were treated with Hoffmann external fixation as a part of their fracture care. Thirteen fractures involved the tibia and one the femur. The average follow-up of these children was 17 months. The Hoffmann device was used for 6 to 20 weeks with an average of 11 weeks. One-half of the children had purulent drainage at some time during their treatment although no chronic infections resulted. Fracture union was present after 12 to 52 weeks with a median of 17 weeks. Three refractures occurred after apparent union. The only final angular deformity was in one patient with 6 degrees of varus. Three patients had leg length discrepancies of 2 cm or more. Four patients had overgrowth of the injured limb of 1.0 to 3.0 cm. Range of motion was not permanently impaired by the Hoffmann device. Use of the Hoffmann device for external skeletal fixation is recommended in children with open fractures with skin loss or burns, in children with head injury with resultant increased motor tone, and in polytrauma patients to facilitate patient care and transport for diagnostic and therapeutic procedures.

Accidents, Traffic↗
PubMed1999

External fixation of open humerus fractures.

Fifteen patients with open shaft of humerus fractures were treated with a monolateral external fixator. Nine patients presented with nerve palsies. Two radial nerves were disrupted and required grafting. Of the seven others, six spontaneously recovered and one brachial plexus partially improved. All fractures healed. The average duration of external fixation was 21 weeks. Four patients required additional procedures prior to healing (external fixator reapplication-2, plating and bone grafting-2). Two of these four experienced breakage of 4.5 mm external fixation pins. Eight patients developed pin tract infections, which all resolved with local care and antibiotics. Thirteen patients were contacted at an average of 63 months after injury. Eleven reported they were satisfied with their result, nine had no functional limits, and eight reported no pain.

Adolescent↗