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PubMed2005

[Trauma surgery in the elderly].

The indications for the surgical treatment of fractures in elderly patients should consider the individual's general health status, the specific pattern of injury, and the ability of the patient to actively participate in the rehabilitation process. Intramedullary systems are the gold standard for shaft and metaphyseal fractures due to the decreased operative trauma and the possibility of early weight bearing and functional treatment. Minimally invasive locking plate systems can frequently be applied, offer decreased risk of secondary fracture displacement, and have great advantages in the treatment of periprosthetic fractures with firm implants. The possible reasons for falls should be diagnosed in order to allow their prevention. An exact assessment of the severity of osteoporosis in important in allowing adequate treatment for associated pain and for decreasing the risk of future osteoporosis related fractures.

Accidental Falls↗
PubMed1986

Surgical stabilization of pathological neoplastic fractures.

The most important factor to consider in deciding between treatment options in the management of metastatic bone disease is the level of the patient's dysfunction and pain. Severe dysfunction or pain demands a treatment that predictably leads to a quick resumption of the painless activities of daily living. A treatment that predictably will restore function in months may seem reasonable in patients with a normal remaining life span, but is untenable if those months represent a high percentage of remaining life span, as they do in metastatic disease afflicted patients. The treating physician needs also to understand the basis for the patient's dysfunction. A destroyed joint will not return to painless function even if the metastasis responsible is totally eliminated. A bone that has lost its structural integrity, even though not grossly fractured, will not support weight bearing for months even if the metastasis is eliminated. Control of the metastatic tumor does not always equate with return to function. Treatment options in the management of metastatic bone disease are not mutually exclusive. In many patients treatment options are combined. Surgical stabilization may best return the patient's function while he is being treated postoperatively with radiotherapy or chemotherapy for good neoplasm control. Neoplasm control should not be such an overriding concern that function is not addressed. Function can almost always be returned to the patient, but neoplasm "cure" is rarely achieved in this group of patients. It is a reasonable goal to avoid allowing bone metastasis to progress to pathological fracture. Routine periodic examinations and bone scans should commonly alert the treating physician to the presence of metastatic bone disease well before fracture occurs. Pathological fracture narrows the range of treatment options, mitigates against full functional restoration, demands a rehabilitation hiatus, and acutely frightens the patient who does not have time to participate fully in treatment decisions. An impending pathological fracture can be treated with surgery, radiotherapy, chemotherapy, or hormonal manipulation. The options are basically operative or nonoperative. Lesions that predictably will fracture short term, involve joints, or will cause catastrophic consequences if fracture occurs should be strongly considered for surgical stabilization. Other factors to consider are the location of the metastasis, the primary tumor, and the expected response to nonoperative therapy. The patient becomes a surgical candidate for the above reasons and not because of any estimated life span.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed2006

[Treatment of osteoporosis--the new role of the orthopaedic surgeon].

Fractures which are caused by falling from standing height or less are named "fragility fractures". These fractures may indicate neglected osteoporosis and will occur even more frequently in the future, due to the demographic change. This is why osteoporosis will become a challenge to our healthcare systems. For the orthopaedic surgeon treatment of osteoporosis was limited to fracture fixation in the past. As this approach is very focussed towards the fracture as the major complication of osteoporosis, there is a big potential for improvement. It is important to know that such patients suffering from a first fragility fracture are at high risk for being hit by a second or further fragility fractures. A fracture prevention programme should therefore become a mandatory requirement for these patients in the future. The orthopaedic surgeons will be the key players who should put this approach into effect. As we treat most patients with fragility fractures it is our privilege to identify those patients who will most likely benefit from fracture prevention.

Age Factors↗
PubMed2005

An economic analysis of management strategies for closed and open grade I tibial shaft fractures.

BACKGROUND: Closed and open grade I (low-energy) tibial shaft fractures are a common and costly event, and the optimal management for such injuries remains uncertain. METHODS: We explored costs associated with treatment of low-energy tibial fractures with either casting, casting with therapeutic ultrasound, or intramedullary nailing (with and without reaming) by use of a decision tree. RESULTS: From a governmental perspective, the mean associated costs were USD 3,400 for operative management by reamed intramedullary nailing, USD 5,000 for operative management by non-reamed intramedullary nailing, USD 5,000 for casting, and USD 5,300 for casting with therapeutic ultrasound. With respect to the financial burden to society, the mean associated costs were USD 12,500 for reamed intramedullary nailing, USD 13,300 for casting with therapeutic ultrasound, USD 15,600 for operative management by non-reamed intramedullary nailing, and USD 17,300 for casting alone. INTERPRETATION: Our analysis suggests that, from an economic standpoint, reamed intramedullary nailing is the treatment of choice for closed and open grade I tibial shaft fractures. Considering financial burden to society, there is preliminary evidence that treatment of low-energy tibial fractures with therapeutic ultrasound and casting may also be an economically sound intervention.

Cost of Illness↗
PubMed1997

Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallée lesion.

Closed internal degloving is a significant soft-tissue injury associated with a pelvic trauma in which the subcutaneous tissue is torn away from the underlying fascia, creating a cavity filled with hematoma and liquefied fat. It commonly occurs over the greater trochanter but may also occur in the flank and lumbodorsal region. When this closed internal degloving occurs over the greater trochanter, it is known as a Morel-Lavallée lesion. We reviewed 24 patients who sustained a closed internal degloving injury. Cultures from the closed internal degloving injury were positive in 46% (11 of 24 cases). The incidence of positive cultures was not dependent on the time from injury to debridement. All wounds were treated by thorough debridement before or during pelvic or acetabular surgery. Three patients subsequently developed deep-bone infections, only one of whom had a positive culture at the initial debridement. One patient whose wound was primarily closed over suction drains developed a chronic deep soft-tissue infection requiring multiple debridements. The development of hematoma in the zone of operation reduces the safety of early operative intervention by increasing the risk of infection. An expanding hematoma in a closed internal degloving injury may further compromise the skin vascularity if not promptly drained. The injured soft tissues should be debrided early, either before or at the time of fracture fixation. The wound should be left open, and repeated surgical debridement of the injured tissue is recommended.

Acetabulum↗