Treatment of complex (Schatzker Type VI) fractures of the tibial plateau with circular wire external fixation: retrospective case review.

OBJECTIVE: To determine the effectiveness of circular wire external fixation in the treatment of complex (Schatzker Type VI) fractures of the tibial plateau. DESIGN: Retrospective case series. SETTING: Fifty-seven complex (Schatzker Type VI) fractures of the tibial plateau were treated with circular wire external fixation at a Level 1 trauma center. PATIENTS: Thirty-five fractures were closed, and twenty-two were open. INTERVENTION: Closed indirect reduction by ligamentotaxis was attempted in all fractures; limited open reduction was performed in seven. Conventional Ilizarov frames using wire fixation were used in thirty-two fractures. The remaining twenty-five fractures were treated with hybrid Ilizarov fixators, which differed from conventional Ilizarov frames only in the use of cortical bone pins rather than wires through the distal rings for fixation of the diaphysis. MAIN OUTCOME MEASUREMENT: The results were graded according to the Knee Society rating system. Follow-up ranged from 16 to 90 months and averaged 42 months. RESULTS: All fractures united at an average of 173 days (range, 50 to 415 days). Forty-five fractures with anatomic reduction had an average knee score of eighty-three and an average functional score of sixty-nine. In nine fractures with nonanatomic reduction, the average knee score was fifty-two, and the functional score was nineteen. CONCLUSIONS: Results perhaps would have been improved by more frequent open reduction, bone grafting, and internal fixation of fractures with severely depressed articular fragments. However, the use of circular external fixation obtained results comparable with other series, and we believe it is appropriate for treatment of these complex tibial fractures, especially those with a poor soft-tissue envelope.

Nonoperative treatment of ipsilateral fractures of the scapula and clavicle.

BACKGROUND: Internal fixation of one or both bones is the recommended treatment for floating shoulder injuries (ipsilateral fractures of the scapula and clavicle). Perceived risks of nonoperative treatment include abduction weakness, decreased range of motion, chronic pain, malunion, and nonunion. None of these problems, however, have been confirmed by clinical studies. The purpose of this retrospective study was to analyze the clinical and radiographic results of nonoperative treatment of floating shoulder injuries. METHODS: Twenty patients with a floating shoulder injury were treated with either a sling or a shoulder immobilizer. Eleven clavicular fractures were displaced ten millimeters or more, and five scapular fractures were displaced more than five millimeters. Physical therapy was begun three days to two weeks after the injury. Patients were evaluated with three separate scoring systems: those of Herscovici et al., Rowe, and Constant and Murley. Shoulder abduction and flexion were measured, and abduction strength was evaluated by clinical examination and comparison with the uninjured extremity. The duration of follow-up averaged twenty-eight months (range, nine to seventy-nine months). RESULTS: Nineteen of the twenty pairs of fractures united uneventfully. One clavicular nonunion occurred secondary to segmental bone loss from a gunshot wound. On the basis of the Herscovici rating system, seventeen patients had an excellent result and three had a good result. According to the Rowe system, eighteen patients had an excellent result, one had a good result, and one had a fair result. The average Rowe score was 95. The average Constant score was 96. In all twenty patients, the strength of the injured extremity was equal to that of the uninjured extremity. Eighteen patients had a full, symmetrical range of shoulder motion, one lost 15 degrees of flexion, and one lost 20 degrees of abduction. CONCLUSIONS: Nonoperative treatment of floating shoulder injuries, especially those with less than five millimeters of fracture displacement, can achieve satisfactory results that are probably equal or superior to those reported after operative treatment, without the risk of operative complications.

Low-velocity gunshot injuries of the spine with abdominal viscus trauma.

OBJECTIVE: To evaluate the risk of infection of the spine and associated complications after colonic or rectal injury associated with gunshot injury of the spine. DESIGN: Retrospective review. SETTING: Presley Memorial Trauma Center, Regional Medical Center, Memphis, Tennessee, a statewide Level 1 trauma center. PATIENTS: Thirty-three patients with gunshot wounds to the spine and associated viscus injury were treated between 1989 and 1994; in thirteen, the bullet passed through the colon or rectum before damaging the spine. INTERVENTION: Six patients received a single antibiotic (Cefotetan) and seven were given multiple antibiotics. Total duration of antibiotic treatment ranged from two to forty-three days. RESULTS: None of the thirteen patients developed osteomyelitis or disc space infection. Most intraabdominal complications were secondary to dehiscence of colonic repair. CONCLUSIONS: Because the magnitude of bacterial colonization of the vertebrae after colonic injury may not be high, a nonoperative approach to treatment of abdominal viscus injuries is appropriate in patients with gunshot wounds to the spine. Broad-spectrum antibiotic coverage for at least seven days appears to be effective in preventing spinal infection, but colonic injuries are associated with an increased incidence of intraabdominal abscess and peritonitis.

Antegrade interlocking nailing of acute humeral shaft fractures.

Between 1992 and 1996, 73 acute humeral shaft fractures in 71 patients were treated with antegrade Russell-Taylor humeral nailing. Sixty (84%) patients sustained multiple trauma, and 26 (36%) fractures were open. Three patients had preoperative brachial artery injuries, and 12 had preoperative nerve palsies. Sixty-nine (94.5%) fractures united primarily, and two additional fractures united after bone grafting. There were no infections. Two (2.7%) iatrogenic radial nerve palsies occurred, and both were transient. Full shoulder function returned in 66 (90%) patients. Two (2.7%) patients had impingement from proximal locking screws, and one (1.4%) had impingement from a prominent nail. Normal elbow function was regained in 96% of patients. All patients without full return of elbow and shoulder function had concomitant injuries. Antegrade Russell-Taylor nailing is an acceptable alternative for the treatment of acute humeral shaft fractures in multiply injured patients.

Fatigue failure in small diameter tibial nails.

The prevalence of implant failure in small diameter tibial nails has not been well characterized. In a series of 130 tibial fractures stabilized with 8-mm and 9-mm nails, implant failure occurred in 18 fractures (13.8%): 4 nails (3%) broke and 16 (12.3%) screws failed. All nail failures occurred in open, unstable fractures with delayed union, and all of the nails that broke were dynamically locked during the failure. Of the 130 fractures, 128 (98.5%) eventually united. Delayed union, degree of comminution, metaphyseal location, and dynamic locking of unstable fractures contribute to hardware failure. Based on these findings, dynamization could be used to treat delayed union only in axially stable diaphyseal fractures. Exchange nailing is recommended to treat delayed union in comminuted or metaphyseal fractures to prevent hardware failure. Bone grafting should be performed at 6 to 12 weeks for fractures with > 50% bone loss.

Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming.

Fifty open fractures of the tibial shaft that were treated with débridement and interlocking nailing without reaming were followed for an average of twelve months. Most of the fractures were the result of high-energy trauma, and 68 per cent of the fracture wounds were grade III. Forty-eight (96 per cent) of the fifty fractures united at an average of seven months; there were no malunions. There were four infections (8 per cent), all at the sites of grade-III fractures. Locking screws broke in five tibiae (10 per cent), but the breakage did not result in a loss of reduction. Three nails broke, two at the sites of ununited fractures and one at the site of a healed fracture. These results are comparable with, or better than, those obtained with other forms of fixation, including immobilization with a cast, unlocked intramedullary nailing, and external fixation.

Neurenteric cyst: surgery and diagnostic imaging.

Neurenteric cysts are rare, with fewer than 30 cases noted in the literature. We report the case of a newborn infant with respiratory distress caused by a large neurenteric cyst that was identified by prenatal ultrasound. Treatment consisted of excision of the mass through a right posterolateral thoracotomy. The cyst adhered to the spine at the level of the first thoracic vertebra and communicated with the jejunum through a posterior diaphragmatic defect. Postoperative studies with magnetic resonance imaging (MRI) and computed tomography (CT) disclosed an anterior meningocele and tethering of the spinal column. This is the second reported case of a neurenteric cyst demonstrated by prenatal ultrasound. The presence of an intrathoracic cyst associated with spinal abnormalities is characteristic of this anomaly. With imaging techniques such as MRI and CT, we may detect residual intraspinal disease associated with neurenteric cysts.

Flexible intramedullary nailing of subtrochanteric fractures of the femur. A multicenter analysis.

In a retrospective, multicenter analysis, 79 subtrochanteric fractures of the femur were treated with flexible intramedullary nails. Seventy fractures were traumatic in origin, three were pathologic, and six occurred in spinal cord patients. All of the fractures healed, and there were no fixation failures. Thirteen patients (16%) required adjunctive internal fixation, bone grafts, or postoperative traction. Shortening greater than 1 cm occurred in four patients (5%). Reoperation with one week of surgery was necessary in eight patients (10%). The single greatest complication was knee complaints, which occurred in 17 patients (21.5%). However, only six of these patients required revision prior to fracture union. In one patient a deep wound infection developed, which eventually healed without evidence of osteomyelitis. All patients who were ambulatory before their fracture were able to bear weight.