Current treatment procedures for civilian gunshot wounds.

INTRODUCTION: This work provides an overview of the incidence of gunshot wounds during peace conditions in a civilian population and aims to assess the principles of their treatment. METHOD: We evaluated a total of 104 patients with gunshot wounds with an average age of 38.7 years (range 1871). 84 men (80.8%) and 20 women (19.2%) were involved. The head was affected 7 times (6.7%). Out of those, penetrating injury occurred only once (1.0%). The throat was hit three times (2.9%). The chest was injured 15 times (14.4%), penetrating injury at this site was observed in 10 cases (9.6%). In five cases the lungs were affected and the heart once. Gastric injury occurred 13 times, penetration into the peritoneal cavity occurred seven times (6.7%). The intestine was injured five times, the liver three times and the gall-bladder once. Limb injury was present in 66 (63.5%) cases and in 19 of those, the injury was associated with a fracture. In 50 cases (48.1%), the patient was attacked by another person. 45 patients (43.3%) injured themselves unintentionally, five patients (4.8%) were injured in a suicidal attempt and four (3.8%) were accidentally shot by someone else. The weapons used were: pistol in 57 (54.8%) cases, air rifle in 20 cases (19.2%), a rifle in 10 cases (9.6%), two patients (1.9%) were injured with a detonator and one (1.0%) with an assault rifle. In 14 cases (13.5%), the type of firearm used was not established. RESULTS: Surgical treatment was indicated in all cases. The first step was always a thorough wound irrigation. Single surgical treatment was performed in 48 cases (46.2%) while the other 56 patients (53.8%) required multiple surgeries. Specialized surgical procedures were performed in a total of 30 cases: seven laparotomies, five thoracotomies, five fracture stabilizations using external fixator, four amputations of limbs, two intramedullary osteosyntheses, two stabilizations with the use of Kirchner wires, two vascular surgeries, one craniotomy and one suture of a peripheral nerve. Complications of healing were not frequent: wound infection was observed in two cases (1.9%), wound dehiscence in one case (1.0%), osteomyelitis in two cases (1.9%), nonunion of the fracture (1.0 %) occurred once and in one case (1.0%), pulmonary embolism was diagnosed which was not fatal. CONCLUSION: Consistent debridement, fasciotomy, and complete drainage of the wound are only indicated in deep gunshot wounds. A surgical revision of the abdominal cavity is indicated for all penetrating abdominal gunshot injuries. The watch-and-wait approach with surgical wound management and hospitalization is only allowed for unambiguously non-penetrating abdominal injuries. Complications of gunshot wound healing in civilian settings are not common and are most often infectious. Key words: gunshot wound - civilian settings surgical treatment.

[Management of diaphyseal forearm fractures using LCP angle- stable fixation devices and intramedullary nailing]. / Resení diafyzárních zlomenin predloktí pomocí uhlove stabilní dlahy LCP a nitrodrenového hrebování.

AIM OF THE STUDY: The aim of this study is to assess treatment outcomes of diaphyseal radial and ulnar fractures using angle- stable LCP device (Synthes, Svýcarsko), compared to ForeSight intramedullary nailing (Smith&Nephew, USA). MATERIAL AND METHODS: The prospective study included 80 patients with 115 forearm fractures, assigned to two equal groups, based on the fixation method. The group included 53 males and 27 females, the mean age was 36.6 years of age (range 18-77). the mean folow up period was 18 months (range 12-32 months). The patients were repetitevely x-rayed and their functional assessment was performed at the same time. Furthermore, treatment- related complications were also evaluated. RESULTS: Two cases of prolonged healing were recorded in the LCP device treatment group. Four cases of prolonged healing were recorded in the intramedullary nailing group, which healed within 18 months and did not require reoperation. The mean fracture healing time was 20.5 weeks (range 9-80 weeks) in the group with intramedullary nailing, and 19.0 weeks (range 12-46 weeks) in the LCP group. No significat differences in surgery time, healing time, postoperative pain scores or final 1-year functional outcomes were detected between the both treatment groups. Statistically significant prolonged healing was demonstrated in the intramedullary nailing group in cases, where fragment dislocation exceeded 3 mm, compared to a group of patients with anatomical repositioning and dislocation of less than 2 mm (p = 0.015; Anova). No cases of deep infections were recorded. Complications, recorded in the intramedullary nailing group, included the following: partial migration of securing nails in two subjects and incomplete synostosis in two subjects. Complications, recorded in the LCP device group, included: early re-fracturing in the original fracture location in a single subject (3 weeks after extraction). DISCUSSION: The results correspond with outcomes of other recent studies. Although open repositioning and internal fixation is considered a standard treatment method in forearm diaphyseal fractures, recently changing opinion on the use of nails in this indication is apparent. Considering ongoing improvements of these implants, the trend of nailing should be more widely accepted. CONCLUSION: Although their concept of fracture fixation is different, the both implants appear indicated for the management of forearm diaphyseal fractures.

[Callus distraction lengthening of the tibia with the intramedullary kinetic nail (case report)]. / Prolongace bérce pomocí kalus-distrakce s vyuzitím kinetického intramedulárního hrebu (kazuistika).

In this report the first experience with callus distraction lengthening using the intramedullary kinetic nail is described. This was performed on a left tibia with a total shortening of 34 mm. The distraction phase lasted 36 days and the rate of distraction was 0.95 mm per day. The full weight-bearing of the treated lower extremity was allowed at 12 weeks after surgery. Complete consolidation of the callus was achieved at 112 days and the consolidation index was 3.21 days/mm. No serious complications were recorded during the post-operative period. At 12 months after surgery, the patient showed a full range of motion in the knee, his ankle range of motion was S 15-0-35, and he achieved an excellent functional outcome on evaluation by Paley's classification.

[Revision surgery in diaphyseal forearm fractures]. / Revizní operace diafyzárních zlomenin predloktí

PURPOSE OF THE STUDY: The aim of the study was to compare the results of revision surgery in diaphyseal fractures of the ulna and radius treated by intra-medullary interlocking nailing or plate osteosynthesis. MATERIAL AND METHODS: The group included 36 patients who, in the period from 2000 to 2005, were treated with the use of the intra-medullary ForeSight nail system (Smith & Nephew, USA) or a small, 3.5 mm auto-compression plate (different manufacturers). Pseudoarthrosis developed in 25 patients and recurrent fractures were found in 11 patients (six of these suffered fractures along the original fracture line after minimal trauma and five showed a recurrent fracture at the site of screw tunnels). The average age of the patients was 37.3 years. The average period between injury and revision surgery was 16 months (range, 4 to 32 months). The follow-up included examination for early and late complications and the evaluation of X-ray findings and functional outcomes. RESULTS: The average follow-up was 21 months (range, 12 to 36 months). For revision surgery, an intra-medullary nail was used in 28 and a plate in 8 patients. The average operative time was 85 min (range, 30 to 180 min). Radiographic union was achieved by 6 months in 30, by 12 months in three and by 18 months in three patients. The average fusion time in the 30 patients healing by 6 months (nailing, 23x, 7x plate osteosynthesis) was 16.05 weeks. The range of motion in the wrist, forearm and elbow was evaluated by the Anderson method. The outcomes were excellent, good and satisfactory in 11, 15 and 10 patients, respectively. Poor results or wrist or elbow stiffness were not recorded. Pain was recorded at rest and in activity, taking requirements for analgesic therapy into account. After revision surgery, 22 patients were free from pain, 10 reported occasional pain during activity and four experienced pain at rest. None of the patients required permanent analgesic therapy. CONCLUSIONS: The results of our study show the effectiveness of plate and nailing techniques in revision forearm surgery. The corrective procedure must be chosen with regard to the type of pseudoarthrosis, and individual therapy respecting the principles of stable osteosynthesis is necessary. A differentiated operative approach, infection control and stimulation of bony union also play important roles.

[Treatment of gunshot wounds and prevention of complications during the healing process]. / Osetrení strelných poranení a prevence vzniku komplikací v prubehu hojení.

INTRODUCTION: The objective of the research is the assessment of the way and results of a case-series of treatment of gunshot wounds and to remain of the requirement of complete wound treatment in peace time. MATERIALS AND METHODS: During the period from 1997 to 2006, we treated 60 patients who had penetrating gunshot wounds. The case series included 12 female and 48 male patients ranging in ages from 18 to 71 years (average age 37 years). Weapons that caused injuries included pistol (33), rifle (5), assault rifle AK-47 (1), air gun (9), firecrackers (2), and unknown weapons (10). We assessed outcomes of different therapeutic approaches by monitoring early and late postoperative complications and by total recovery time. RESULTS: Two patients died within the first 24 hours; no other patients die after the first 24 hours of initiation of treatment. Thirty-nine patients were hospitalized with hospital stays ranging from 1 to 40 days (average length of stay 13.2 days). Total recovery time varied from 3 to 330 days averaging 65.7 days until full recovery and ability to work. Fifteen patients had bone injury, eight of which needed osteosyntesis. Four patients received external fixators, two were treated by titanium intramedullar nail, and two by transfixation with Kirchner wire eighteen patients (30%) had secondary sutures. Perioperative complications were osteomyelitis (two patients), pseudoarthrosis of upper extremity proximal phalange (one patient) and non-lethal pulmonary embolism (one patient). CONCLUSION: Standard treatment of penetrating gunshot wounds should consist of primary and prompt detailed debridement, sufficient fasciotomy, and complete drainage of the wound.

[Treatment of proximal humeral fractures by angular stabile, antegrade, interlocking intramedullar nail]. / Osetrení zlomenin proximálního humeru pomocí úhlove stabilního antegrádního zajisteného nitrodrenového hrebu--prospektivní studie.

INTRODUCTION: The objective of our study is evaluation of clinical and radiological results of dislocated proximal humeral fractures, treated by direct, angular stabile, antegrade and interlocking implants Targon PH (Aesculap, Tuttlingen, Germany). METHODS: We evaluated 102 patients (76 female and 26 male), average age was 67.3 years (26-87 years). The standard nail was used in 73 cases; the long one was used in 29 cases. We interpreted functional results (Constant's score and relative Constant's score), radiological results and postoperative complications. RESULTS: Constant's score achieved average 51.3 points--3 weeks after operation, 67.4 points--after 6 months and 75.8 points--after 1 year. Value of the relative Constant's score was 59.3%, 75.9% and 83.5%. We have found trend to the poorer functional outcomes in all complicated four-part fractures; especially in cases with disarticulation. The complete bone healing was reached in: 63.7% up to 3 months, 95.1% up to 6 months and 99% up to 1 year. We detected lecase of the pseudoarthrosis. We had 37 complications in our 102 patients group in the first year after operation. The migration of the proximal fixation screws was most frequent complication--12 patients. Eight times the humeral head aseptic necrosis appeared (5x partial, 3x complete), 3 times redislocation of tuberculum maius was found. We made reoperation 2 times by Phillos plate (1x for pseudoarthrosis, 1x for broken screws). CONCLUSIONS: Targon PH is intramedullary nail stabilisation of proximal humeral fractures by angular stabile, antegrade, interlocking system. We consider it for mini-invasive technique that provides high stability in osteoporotic bone and allows immediate postoperative shoulder mobilisation.

[Hemipelvectomy, constant surgical dilema]. / Hemipelvektomie, konstantní chirurgické dilema.

INTRODUCTION: In this report we present our experience in "post war" environment in our institution. Any king of pelvic surgery is challenging and impacts significantly on limb and visceral function. Any surgeon has to ask a question "is heroic surgery justifiable". We aim to asses functional, oncologic and surgical outcomes following pelvis tumor resections. MATERIALS AND METHODS: Between 1998-2005, 7 patients (mean age 48.2 years) underwent pelvic tumor resections. All of them were primary malignant tumors. We did not identify secondary tumors and benign tumors in our series. Bone tumors were 3 osteosarcomas and 4 chondrosarcomas. Tumors involved the ilium, acetabulum, pubic bones, sacrum or a combination of these. No patient had metastases at presentation. RESULTS: All 7 patients underwent hindquarter amputations. Surgical margins were marginal (4), wide (2), and radical (1). There was 1 intraoperative death, 2 local recurrences and 2 metastases. Death from disease occurred at a mean of 12.4 months with mean follow-up of 24 (1-72) months. Emotional acceptance was surprisingly high. Pelvic resections are complex. Functional outcome is significantly affected by surgery. Disease control is similar to limb tumors. Emotional acceptance of surgery in survivors was surprisingly high. CONCLUSION: Major pelvic resection for malignancy appears justified.