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PubMed1998

Internal fixation of multiple fractures in patients with polytrauma.

Within the last decade understanding of the pathogenetic consequences of trauma has been improved significantly. An additional reduction of lethality has been achieved that in part is related to increasing discrimination of complex injury patterns. Accordingly, additional staging in fracture management of these injuries has been developed. An overview of the current status of fracture management in polytrauma is given and certain regimens that are still controversially are discussed. The principles determined are based on the treatment experience of 4003 multiply injured patients within the past 23 years. The most important principles within the first hours after trauma represent adequate hemorrhage control. In fracture treatment the primary goal remains to perform primary stable osteosynthesis. In severe polytrauma with severe injuries to the extremities, the first decision is whether limb salvage can be achieved without risk of deterioration of the patient's condition. If this is the case, open fractures Grades III b and c usually can be stabilized primarily by unreamed intramedullary nailing or percutaneous plating. The priority pattern in multiple closed fractures is as follows: (1) tibia; (2) femur; (3) pelvis; (4) spine; and (5) upper extremity. Exceptions may ensue if severe head or thoracic trauma is present. Delayed treatment is performed for complex joint reconstruction, definitive treatment of maxillofacial injuries, and soft tissue reconstruction.

Algorithms↗
PubMed1992

Intense granulomatous inflammatory lesions associated with absorbable internal fixation devices made of polyglycolide in ankle fractures.

Since absorbable internal fracture fixation devices made of polyglycolide have been increasingly used clinically, a peculiar type of complication has emerged. After an initially uneventful course, a local nonbacterial inflammatory reaction appears two to four months after the operation, resulting in a copiously discharging sinus on the skin. A series of 286 patients with unimalleolar or bimalleolar fractures were treated by open reduction and internal fixation using cylindrical rods made of polyglycolide. Among these there occurred 18 nonbacterial inflammatory tissue responses (6.3% of the total) requiring surgical drainage. Six patients had an intense reaction necessitating repeated surgical measures and inpatient management. The hospital stay of these patients averaged 18 days. The mean duration of the discharge from the lesions was 10.8 weeks. Microscopic examination of biopsy specimens showed a nonspecific foreign-body reaction composed mainly of neutrophilic polymorphonuclear leukocytes and foreign-body giant cells phagocytizing the polymer debris left behind by the decomposing implants. On roentgenograms, osteolytic increase of the diameter of the implant channels was observed, but the bony union of the fracture seemed not to be disturbed. Thus the factors increasing the susceptibility of some individuals to this complication remain unknown.

Ankle Injuries↗
PubMed1990

The Brain laryngeal mask. An alternative to difficult intubation.

We report the case of a young man undergoing fixation of bilateral mandibular fractures, where the anaesthetist was unable to intubate. A Brain laryngeal mask was employed, thus enabling surgery to proceed. This relatively new device enabled the airway to be safeguarded whilst preserving reasonable surgical access for the attachment of Erich arch bars and a four hole osteosynthetic bone plate. The surgical and anaesthetic procedures are summarised. The laryngeal mask is described and its performance and limitations are discussed. We believe this to be the first report of mandibular fracture fixation performed with a Brain laryngeal mask in situ.

Adult↗
PubMed1988

Patellar fixation protected with a load-sharing cable: a mechanical and clinical study.

The stability of patellar fracture fixation protected with a load-sharing cable was studied in cadavers. A transverse patellar osteotomy was produced and stabilized with standard patellar fixation with or without a figure-of-eight cable that extends from the proximal pole of the patella to the tibial tubercle. Standard fixation techniques (interfragmentary cancellous screws or modified tension-band wiring) alone failed after significantly fewer cycles of flexion and extension than did the same fixation when supplemented with a load-sharing cable. In the clinical evaluation of the load-sharing cable, 14 consecutive patients with displaced patellar fractures were treated. No immobilization was used and the patients were started on passive and active range of motion and weight-bearing ambulation in the early postoperative period. Thirteen fractures healed uneventfully. The increased stability of patellar fracture fixation protected with a load-sharing cable offers three advantages: (a) adjunctive casting is unnecessary, (b) comminuted fractures can be "pieced" together anatomically with less concern for loss of fixation, and (c) early postoperative passive and active range of motion can be achieved.

Adolescent↗
PubMed2002

Percutaneous screw fixation for fractures of the sesamoid bones of the hallux.

Over a period of one year we treated nine fractures ofhe sesamoid bones of the hallux, five of which were in the medial sesamoid. All patients had symptoms on exercise, but only one had a recent history of injury. The mean age of the patients was 27 years (17 to 45) and there were six men. The mean duration of symptoms was nine months (1.5 to 48). The diagnosis was based on clinical and radiological investigations. We describe a new surgical technique for percutaneous screw fixation for these fractures using a Barouk screw. All the patients were assessed before and after surgery using the American Orthopaedic Foot and Ankle Society Hallux Score (AOFAS). There was a statistically significant improvement in the mean score from 46.9 to 80.7 (p = 0.0003) after fixation of the fracture with a rapid resolution of symptoms. All patients returned to their previous level of activity by three months. We believe that this relatively simple technique is an excellent method of treatment in appropriately selected patients.

Adolescent↗
PubMed1997

Risk of pelvic injury from femoral neck guidewires.

Many of the devices used in the internal fixation of femoral neck fractures are cannulated and require the initial placement of one or more guidewires for accurate positioning. These wires are occasionally advanced inadvertently through the hip joint and the acetabulum. Pelvic visceral damage may follow. To assess this risk, we inserted three guidewires to a depth of 16 cm into each femoral neck of ten cadavers and explored the pelvis during autopsy. Thirty-two of the 60 guidewires had penetrated a pelvic organ. The literature on intrapelvic injuries associated with hip surgery is reviewed, and suggestions are offered on the avoidance of pelvic penetration during hip fracture fixation.

Cadaver↗
PubMed1993

A comparison of the strength and stability of six techniques of cerclage wire fixation for fractures.

An in vitro comparison of six methods of cerclage wire fixation was performed using 1-mm-diameter stainless steel wire. A testing apparatus was designed to simulate the tensile forces on a cerclage wire around a femoral shaft fracture. The hairpin cerclage knot that we describe generated significantly higher initial compressive force (p < 0.001) and had significantly higher tensile strength (p < 0.02) compared with the other five methods.

Bone Wires↗
PubMed1995

Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls.

OBJECTIVE: To determine the effect of the timing of fracture fixation and the physiologic status on admission of elderly patients with hip fractures from low impact falls on resource utilization and outcome. METHODS: A 5-year retrospective review of 82 elderly (age > 65 years) patients with isolated low-impact hip fractures stratified into early (< 24 hours), intermediate (24 to 72 hours), and late (> 72 hours) operative fixation. Admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores, number of comorbidities, fracture type, complication rate, length of stay, discharge acuity, and mortality were calculated for each group. RESULTS: Values are mean +/- SD. The mean admission APACHE II score of the entire group was 8.1 +/- 0.2, indicating that these patients were physiologically stable on arrival. The mean numbers of comorbidities or APACHE II were not significant between groups. No differences existed in the mean APACHE II scores for survivors and nonsurvivors (7.95 +/- 2.34 vs. 9.17 +/- 3.06, p = 0.2409). There were no differences in the mean APACHE II scores and predicted survival for each group. However, a significant decrease in actual survival was observed with late fixation (p < 0.001; Fisher's Exact Test). Patients who were fixed late also had a significantly higher infectious morbidity (p = 0.00469), length of stays (p = 0.0226), and total hospital cost (p = 0.0001), compared with those fixed early or immediate, despite having no difference in average acuity upon discharge (p = 0.3883). CONCLUSIONS: Delay in fracture fixation, in elderly patients who are physiologically stable on admission, significantly increases morbidity and mortality and adversely affects resource utilization.

APACHE↗
PubMed1987

Stability of fixation in femoral neck fractures. Comparison of four fixation devices in vivo and in cadavers.

On human cadaveric femora, internal fixation of cervical osteotomies was performed with four different devices. With the use of a lever, a static force was applied through the acetabulum to the osteotomy site. Motion at the osteotomy site was measured by two strain gauges. The compression force necessary to inhibit motion at the osteotomy site during the fixation procedure was measured. This force was lower with a hook pin than with the other devices. During surgery in 12 patients with displaced femoral neck fractures, the forces holding the fracture surfaces together were measured with a dynamometer. The force at which widening of the fracture gap was observed by fluoroscopy was recorded. In seven fractures, the mean compression force was 110 (60-170) N. The remaining five fractures did not open up when pressures of up to 200 N were applied. These forces were always greater than the hook pin forces measured in the cadaver experiments, but often less than the forces obtained with the other devices.

Aged↗
PubMed1992

[Experimental study of external fixation of femoral fractures. Mechanical properties of different kinds of fixation. Clinical implications].

An in vitro assessment of the mechanical performance of 10 types of external femoral stabilization allowed the amplitudes of fracture site displacements during the initial loading phase of a comminuted fracture treated by external fixation to be established. The largest displacement to load ratios were observed in the sagittal plane for all tested configurations. The highest fixator stiffnesses were obtained by using large diameter tubes and pins. The most rigid fixators have a derigidification system which creates the problem of choosing the ideal time to change the rigidity.

External Fixators↗
PubMed2005

Treatment of zygomatic fractures without inferior orbital rim fixation.

Zygomatic fractures can be associated with functional and esthetic problems. Recent improvements in surgical techniques and materials have enabled stable fixation of zygmomatic fractures. Multiple-point fixation is most commonly used for internal fixation. Generally, reduction and fixation are performed through lateral brow, subciliary, temporal, or intraoral incisions (three-point fixation). Our experience indicates that postoperative scarring and sensory disturbances are caused by a subciliary incision with inferior orbital rim fixation. It is thus recommended that inferior orbital rim fixation with mini- or microplates be avoided. In patients in whom the fracture does not involve the orbital floor, reduction of the zygoma and zygomatic arch through a temporal incision is performed at this institution. Fixation of the lateral zygomaticomaxillary buttress and anterior wall of the maxilla with miniplates through an intraoral incision is also performed. If necessary, zygomaticofrontal suture fixation with a miniplate or wire is performed through a lateral brow incision. The status of inferior orbital rim reduction is confirmed by palpitation. Inferior orbital rim fixation with mini- or microplates is recommended for reduction of comminuted fractures and orbital floor fractures with herniation of internal orbit components. Patients who did not undergo inferior orbital rim fixation were free of inferior orbital rim deformity, diplopia, and postreduction rotation.

Adolescent↗