Treatment of type II and type III open tibia fractures in children.

OBJECTIVES: To determine whether severe open tibial fractures in children behave like similar fractures in adults. DESIGN AND SETTING: A combined retrospective and prospective review evaluated treatment protocol for type II and type III open tibial fractures in children over a ten-year period from 1984 to 1993. PATIENTS: Twenty-three fractures were studied in children aged 3.5 to 14.5 (18 boys and 5 girls). There were six type II, eight type IIIA, and nine type IIIB fractures. Type I fractures were not included. Seven fractures were comminuted with significant butterfly fragments or segmental patterns. INTERVENTION: Treatment consisted of adequate debridement of soft tissues, closure of dead space, and stabilization with external fixation. Bone debridement only included contaminated devitalized bone or devitalized bone without soft tissue coverage. Bone that could be covered despite periosteal stripping was preserved. MAIN OUTCOME MEASUREMENTS: Clinical and roentgenographic examinations were used to determine time to union. RESULTS: All fractures in this series healed between eight and twenty-six weeks. Wound coverage included two flaps, three skin grafts, and two delayed primary closures. No bone grafts were required. There were no deep infections, growth arrests, or malunions. Follow-up has ranged from six months to four years. CONCLUSIONS: Open tibia fractures in children differ from similar fractures in adults in the following ways: soft tissues have excellent healing capacity, devitalized bone that is not contaminated or exposed can be saved and will become incorporated, and external fixation can be maintained until the fracture has healed. Periosteum in young children can form bone even in the face of bone loss.

Lateral condyle fractures in children: evaluation of classification and treatment.

OBJECTIVE: To compare intra-operative findings of fractures of the lateral condyle of the humerus in children with existing pre-operative radiographic classification. DESIGN: Prospective, consecutive. SETTING: Large urban hospital. PATIENTS: 25 consecutive displaced lateral condyle (humerus fractures) in 25 children diagnosed on biplanar radiographs. INTERVENTION: Open reduction and internal fixation through a lateral approach to the elbow. MAIN OUTCOME MEASUREMENTS: Anatomic variations of the lateral condyle of the distal humerus based upon intra-operative observations; comparison of findings with pre-operative radiographic classification. RESULTS: Three anatomic types were identified: 1) nine fractures exited on the medial side of the capitellum in the capitello-trochlear groove (36%), 2) eleven fractures exited beyond the capitello-trochlear groove through the trochlear epiphysis (44%), and 3) five fractures extended across the physis medially (20%). No fracture appeared to transverse the ossified portion of the capitellum (Milch Type I). The Milch anatomic classification was found to be inaccurate in 52% of the fractures. CONCLUSION: Intraoperative findings did not correlate with the presumed preoperative radiographic diagnosis in the majority of cases. A heightened awareness of the limitations of this traditional classification system is required for operative decision.

The use of an anterior incision of the meniscus for exposure of tibial plateau fractures requiring open reduction and internal fixation.

The purpose of this study was to examine the use of an anterior incision of the meniscus for exposure of tibial plateau fractures. We studied 27 fractures of the proximal tibia treated with open reduction and internal fixation (ORIF). There were nine unicondylar fractures (five A-O B2; four A-O B3) fixed with plates and screws and 18 bicondylar fractures (seven A-O C1; five A-O C2; six A-O C3) fixed with combination internal and external fixation. Length of follow-up averaged 26 months. All patients were treated with an anterior incision of the meniscus and retraction with the condyle. Of the 18 bicondylar fractures, nine severely displaced fractures were found to have peripherally detached menisci. Unicondylar fractures did not display this finding. After fixation, menisci were repaired at the periphery and sewn to the original anterior insertion. The repair begins posteriorly and advances the cartilage to ensure anatomic placement. There were four medial and 23 lateral menisci in this series. Ten patients underwent knee arthroscopy 6 months to 2 years post-ORIF as a routine procedure during hardware removal. All menisci were found to be healed to the periphery and were stable. There were no gross tears. In one patient, the anterior meniscal incision could be visualized. No patients developed mechanical symptoms either in postoperative rehabilitation or postoperative follow-up at a maximum of 6 years. All patients had > 125 degrees of motion. Less motion when compared with the normal knee was felt to be related to more complex fracture patterns. In conclusion, the anterior meniscal incision allows for excellent exposure of severe proximal tibia fractures. This technique allows for anatomic meniscal repair and early rehabilitation. Arthroscopic examination confirms peripheral meniscal healing. No patient experienced clinical symptoms of meniscal pathology.

The use of combination internal fixation and hybrid external fixation in severe proximal tibia fractures.

Forty-eight patients with 50 severe fractures of the proximal tibia were followed prospectively for 2-4 years (mean 2.7 years) to evaluate the use of limited internal fixation combined with external fixation in the treatment of these injuries. There were 27 men and 21 women ranging in age from 20 to 74 years. Fractures were classified according to the A0 system (Mast J, Ganz R, Jacob R: Planning and reduction technique in fracture surgery. Berlin, Springer-Verlag, 1989), which included 5 A3, 6 C1, 16 C2, and 23 C3 fractures. All patients in this series healed; 48 fractures healed in an average of 12 weeks without subsequent surgery. There were two (4%) nonunions requiring bone graft. The average hospital special surgery knee score was 90 (68-100). Grading criteria for anatomical outcome revealed there were 17 (34%) excellent results, 24 (48%) good results, 6 (12%) fair results, and 3 (6%) poor results. In conclusion, this treatment method is associated with a high percentage of good and excellent results. Combined internal and external fixation combines the advantages of anatomic, stable fixation with less soft-tissue dissection and eliminates the need for large implants.

Displaced pilon fractures. An update.

In the past, displaced pilon (hammer) fractures were considered to be inoperative. When principles for open reduction and internal fixation of pilon fractures were developed, encouraging surgical results emerged. This article deals with the classification, treatment, technique of fixation, and care of this type of fracture.

Collapse of intertrochanteric hip fractures fixed with sliding screws.

A retrospective analysis of postoperative fracture collapse was performed using data from 142 patients with intertrochanteric hip fractures fixed anatomically with sliding screws. Of the 142 patients, 80 had unstable, three- or four-part hip fractures. Significant collapse (as defined by strict radiographic criteria relating the height of the femoral head to the greater trochanter and by Doppelt's criteria) was seen in 26 of the unstable fractures. The degree of collapse was classified as type I (minimal), type II (moderate), and type III (severe). Average follow-up was 31 months. An in-depth clinical and radiographic analysis was performed evaluating pain, limp, abductor weakness, and leg-length discrepancy. The numerical degree of both vertical and horizontal fracture collapse was also analyzed. Of the patients with moderate or severe collapse, 93% had a poor functional result, whereas all the patients with minimal collapse remained asymptomatic. Although postoperative fracture impaction of hips fixed with sliding screws may promote early healing, a high rate of union, and a low rate of hardware failure, excessive collapse is a problem that needs to be addressed.

Development of the acetabulum and hip: computed tomography analysis of the axial plane.

Acetabular growth and development in the axial plane was evaluated by computed tomography (CT) scan. One hundred seventy normal hips of children ranging in age from 6 months to 17 years were evaluated for axial acetabular index, anterior and posterior center-edge angles (CEA), and acetabular anteversion. The acetabulum deepens and becomes increasingly spherical with time until the age of 13 years. Little further change in acetabular shape occurs once the triradiate cartilage closes. Closure ensues between the ages of 11 and 13 years, occurring slightly earlier in girls. Posterior bony coverage of the femoral head is greater than anterior coverage at all times. Acetabular anteversion showed little change as the acetabulum developed. Establishing normal values for axial development of the hip and acetabulum allows a better three-dimensional concept of the different pathologic conditions and aids in treatment planning.

Neuropathic foot ulceration in patients with myelodysplasia.

To determine if a significant relationship existed between type of operation and eventual development of pedal skin breakdown in a spina bifida patient population, 72 feet in 36 ambulatory patients with low lumbar or sacral myelomeningocele were followed for an average of 14 years 5 months. Using a clinical classification for foot suppleness and position, we determined that foot rigidity, nonplantigrade position, and performance of surgical arthrodesis were clinical indicators that had a strong statistical relationship with eventual development of neuropathic skin changes.

Postoperative radiographs as predictors of clinical outcome in unstable ankle fractures.

This study reviews a group of 80 consecutive displaced ankle fractures treated operatively and followed for an average of 3.2 years. Fractures included bone or combined bone and ligamentous injuries in which the initial talar displacement was greater than or equal to 2 mm. The immediate postoperative roentgenograms were examined for several features, which included widening of the syndesmosis, fibular length, talo-crural angle, talar tilt, presence and size of a posterior malleolar fracture, and an abnormality of the medial clear space. Patients were examined at follow-up per Cedell, and their clinical evaluations were correlated with the analysis of radiographic features and demographic data. Good to excellent results were seen in 80% of the cases. The radiographic factors most predictive of a poor outcome were abnormal medial clear space and the presence of a large (greater than 20%) posterior malleolar fracture (p less than 0.05). Fibular shortening, talar tilt, and syndesmotic widening suggested a poor result, but these findings were not statistically significant. Multiple (two or more) radiographic abnormalities correlated with a poor prognosis. Conversely, a perfect radiographic result did not guarantee an excellent clinical outcome. Older patients and those with a delay between injury and surgery greater than 7 days tended to have a poorer result.

Effect of specific antibodies on chronic echovirus type 5 encephalitis in a patient with hypogammaglobulinemia.

The effects of specific antibodies in chronic echovirus type 5 (echo 5) encephalitis were investigated in a patient with x-linked hypogammaglobulinemia. Virus was detected in cerebrospinal fluid (CSF) and blood despite treatment with commercial human gammaglobulin that contained low titers of antibodies to echo 5 (0.6 x 10(4) units per injection). Virus disappeared from blood and CSF when plasma containing high concentrations of antibodies (total dose, 1--4 x 10(4) units/kg) was administered intravenously. Maximal inhibition of virus was achieved in culture and in the patient's CSF when the titer of antibody to echo 5 in CSF was greater than or equal to 16 units/ml. Although the patient died, hyperimmune plasma improved the neurologic status and eliminated detectable virus from the blood and CSF.

Polistes wasp hypersensitivity: diagnosis by venom-induced release of histamine in vitro.

Polistes wasps cause a majority of Hymenoptera-induced anaphylactic reactions in Texas. Using the in vitro release of histamine from basophils of patients allergic to Polistes stings, we have studied the cross-reactivity of venoms from three species of Polistes wasps as well as the cross-reactivity among Polistes, honeybee, and Vespula maculifrons (yellow jacket) venoms. Venom collected by an extrusion technique from Pollistes exclamans, Pollistes apachus, and Pollistes carolina caused release of histamine in seven Polistes-sensitive individuals. The dose-response curves from all three Polistes species were quite similar, suggesting extensive cross-reactivity among these species. None of these patients showed significant release of histamine from leukocytes exposed to yellow jacket or honeybee venom. We conclude that a source of Polistes venom is available for further study and possibly for therapy. It appears that any of three local common species of Polistes wasps could be used. Our studies confirmed earlier reports that Hymenoptera sensitivity if often genus-specific.

The measurement of free erythrocyte porphyrin (FEP) as a simple means of distinguishing iron deficiency from beta-thalassemia trait in subjects with microcytosis.

Assay of free erythrocyte porphyrin (FEP) and measurement of red cell indices were obtained in a group of subjects with iron deficiency and beta-thalassemia trait to determine if these studies cound detect these disorders and discriminate bbetween them. FEP values were increased in 90.2 per cent of subjects with iron deficiency but were within the normal range in 96.6 per cent of subjects with beta-thalassemia trait. Mean FEP values increased sligtly as transferrin saturation fell but became abnormally elevated when the transferrin saturation fell but became abnormally elevated when the transferrin saturation was less than 15 per cent. Unlike subjecs with iron deficiency in whom the mean corpuscular volume varied from 46 to 84, all individuals with beta-thalassermia trait exhibited microcytosis. In most instances, determination of FEP appears to distinguish beta-thalassemia trait from iron deficiency in patients with microcytosis.