Extravasation injuries.

OBJECTIVES: To evaluate the time and type of treatment following extravasation from intravenous infusion and the sequelae of the injuries. METHOD: The charts of 12 patients who were referred to the Plastic and Orthopaedic Services at the University Hospital of the West Indies were reviewed. The study period was between May 2003 and January 2007. Data were collected on age, gender, site of extravasation, extravasated agent, treatment of the extravasation, necrosis interval, duration of hospital stay for treatment of injury and whether the intravenous line was resited and at what site in relation to the injury. RESULTS: The age of patients ranged from three days to 67 years. The female-to-male ratio was 2:1. In five patients, the intravenous infusion was discontinued immediately after the swelling was noticed. In two patients, the intravenous infusion was stopped after seven hours and in five patients it was discontinued within 12 to 22 hours. The necrosis interval ranged from 12 hours to three weeks. Immediate treatment following extravasation and discontinuation of the infusion included limb elevation in three patients and application of cold compresses in one patient. Eleven patients developed skin necrosis of varying severities. There was no skin necrosis in one patient. Ten patients spent an average of 31 extra days in hospital for treatment of the extravasation injury. Two patients were treated in an out-patient clinic. CONCLUSIONS: Extravenous leaks can cause severe tissue injuries. Morbidity is increased by delay in recognition and treatment of the extravasation. A protocol for the treatment of extravasation is recommended.

Donor site morbidity following iliac crest bone graft.

OBJECTIVES: To evaluate the complications of harvesting autogenous bone from the iliac crest. METHODS: A retrospective review of patients undergoing iliac crest bone grafting at the University Hospital of the West Indies, during the period 2000-2004, was performed. One hundred and three patients were identified. Thirty-two patients were successfully contacted and 30 completed the questionnaire. There were 18 males (60%) and 12 females (40%). Their ages ranged from 13 years to 80 years (average 45.6 years). RESULTS: Of the 30 patients, 22 (73.3%) had complications. Fourteen (46.6%) patients had temporary pain; five (16.6%) had chronic pain. Two (6.6%) changed position of clothing due to discomfort at the graft site; five (16.6%) experienced difficulty walking, one reported itching of the scar one had altered sensation and one was unhappy with the scar. Fourteen patients (46.6%) had minor complications and eight patients (26.6%) had major complications. CONCLUSION: Autogenous iliac crest bone grafting is associated with significant complications.

The Illizarov method in infected non-union of long bones.

OBJECTIVE: To review the results of the management of infected non-union of long bones using the Illizarov fixator. METHODS: Eight patients with non-union of long bones associated with current or prior infection were treated between 1998 and 2006. Seven patients were treated between 2004 and 2006. There were seven males and one female with an average age of 32 years (range 17-53 years). Four non-unions were located in the tibia, two were present in the humerus, one was present in the femur and one was intraarticular. Five non-unions were treated with acute compression, two were treated with bone transport and the frame was used in a static mode in one. RESULTS: There was one excellent, three good, one fair and three poor results. CONCLUSION: The Illizarov technique is an important treatment method for surgeons performing posttraumatic reconstructive surgery. Non-union, infection, shortening and deformity are all addressed simultaneously.

Treatment of congenital pseudarthrosis of the tibia with the Ilizarov technique. Case report and review of the literature.

Congenital pseudarthrosis of the tibia continues to pose one of the most difficult problems in paediatric orthopaedic surgery. The surgical procedures most used for treating congenital pseudarthrosis of the tibia are intramedullary nailing associated with bone grafting, vascularized fibular graft and the Ilizarov external circular fixator. Even when union is achieved, the residual deformities in the affected limb often result in significant disability. These deformities include leg-length discrepancy, angular tibial deformities, ankle mortise valgus and fibular non-union. The Ilizarov method allows simultaneous excision of the pseudarthrosis site, correction of the deformity and lengthening. However, refractures, ankle joint stiffness, fibular non-union with progressive ankle valgus are frequent sequelae with the Ilizarov technique. The surgeon should know when to abandon reconstructive procedures and create a more functional patient with an amputation. The authors discuss the indications and results of the Ilizarov external fixator in two patients with this complex problem. In addition, a critical review of the current literature is undertaken.

The accuracy of joint line tenderness in the diagnosis of meniscal tears / Precisión del dolor en la línea de la articulación en el diagnóstico del desgarro meniscal

The accuracy of joint line tenderness in the diagnosis of meniscal tears was assessed in 129 knees. Arthroscopy was performed in each case to establish the diagnosis. The diagnosis was correct in 100 knees (77.5%) and incorrect in 29 (22.5%). A preoperative diagnosis of a medial meniscal tear was made in 63 knees and confirmed in 46 (73%) at arthroscopy. There were 46 true-positive, 17 false-positive, four false-negative and 62 true-negative results for the medial side. A lateral meniscal tear was suspected in 45 knees and confirmed in 39 (86.7%). Thus, 39 true-positive, six false-positive, two false-negative, and 82 true-negative interpretations were found. In this study, joint line tenderness as a test for lateral meniscal tears was accurate (93%), sensitive (95%), and specific (93%), but for medial tears the rates were lower.

La precisión del dolor en la línea de la articulación a la hora de hacer el diagnóstico del desgarro meniscal fue evaluada en 129 rodillas. En cada uno de los casos se realizó una artroscopia a fin de determinar el diagnóstico. El diagnóstico fue correcto en 100 rodillas (77.5%) e incorrecto en 29 (22.5%). Se llevó a cabo un diagnóstico preoperatorio del desgarramiento meniscal medial en 63 rodillas, confirmado en 46 (73%) por artroscopia. Hubo 46 resultados verdadero-positivos, 17 falsopositivos, 4 falso-negativos y 62 verdadero-negativos para el lado medial. Se sospechó un desgarro meniscal lateral en 45 rodillas, y se confirmó en 39 (86.7%). Por consiguiente, se hallaron 39 interpretaciones verdadero-positivas, 6 falso-positivas, 2 falso-negativas, y 82 verdadero-negativas. En este estudio, el dolor en la línea de la articulación como prueba para el desgarro meniscal lateral fue preciso (93%), sensible (95%), y específico (93%), pero para el desgarro medial los índices fueron más bajos.

Femoral lengthening using the Ilizarov technique.

The Ilizarov method allows the surgeon to perform extended lengthening of both congenital and acquired short limbs. The technique can be difficult, time consuming and is associated with many complications. Generally, the number of complications and failures of lengthenings increases in proportion to the length of the distraction and the severity of the preoperative problems. The rate of major complications decreases substantially as the experience of the surgeon increases.

The accuracy of joint line tenderness in the diagnosis of meniscal tears.

The accuracy of joint line tenderness in the diagnosis of meniscal tears was assessed in 129 knees. Arthroscopy was performed in each case to establish the diagnosis. The diagnosis was correct in 100 knees (77.5%) and incorrect in 29 (22.5%). A preoperative diagnosis of a medial meniscal tear was made in 63 knees and confirmed in 46 (73%) at arthroscopy. There were 46 true-positive, 17 false-positive, four false-negative and 62 true-negative results for the medial side. A lateral meniscal tear was suspected in 45 knees and confirmed in 39 (86.7%). Thus, 39 true-positive, six false-positive, two false-negative, and 82 true-negative interpretations were found. In this study, joint line tenderness as a test for lateral meniscal tears was accurate (93%), sensitive (95%), and specific (93%), but for medial tears the rates were lower.

Judet quadricepsplasty for extension contracture of the knee.

Extension contracture of the knee is a well known complication of severe femoral fractures, especially in the supracondylar region. Traditional management by the Thompson quadricepsplasty may result in a variable return of knee flexion and the possibility of significant extension lag. The Judet technique of quadricepsplasty offers the advantages of a controlled, sequential release of the intrinsic and then the extrinsic components limiting knee flexion and a reduced potential for iatrogenic quadriceps rupture or extension lag. The modified Judet quadricepsplasty has definite advantages over the Judet technique since it usually involves less soft tissue dissection and consequently less blood loss.

Treatment of pilon fractures using the Ilizarov technique. Case reports and review of the literature

Tibial pilon fractures are difficult to manage because of their severity. These injuries are frequently open and contaminated, with marked comminution of the articular surface and metaphysis. The results of open reduction and internal fixation are dependent on the severity of the initial injury and the quality and stability of the reduction. The literature reports numerous complication rates associated with open reduction and internal fixation of pilon fractures. The Ilizarov technique of external fixation has fewer complications, and allows restoration of joint surfaces, reconstruction of length, and alignment of the extremity while maintaining a sufficient range of joint motion. Two cases of pilon fractures in which the Ilizarov method was utilized are reported, along with a review of the literature.

Iatrogenic ulnar neuropathies post-pinning of displaced supracondylar humerus fractures in children.

A retrospective review of 141 displaced supracondylar fractures in children at the Bustamante Children's Hospital and the University Hospital of the West Indies from 1994 to 1999 revealed ten ulnar nerve palsies. Of the 141 supracondylar fractures, 27 were treated with open reduction and internal fixation, while 114 had closed reduction and percutaneous pinning. All fractures were fixed with crossed Kirschner wires. Of the ten cases, the ulnar nerve was explored in two cases; the medial pin was removed in two cases, while the other six cases were observed. Follow-up ranged from three to 18 months. Full nerve recovery occurred in all cases except one in which there was partial return of function. Recommendations are made regarding the management of these injuries.

The Ilizarov technique in the treatment of tibial bone defects. Case reports and review of the literature.

Autogenous cancellous bone grafting has long been the hallmark of skeletal defect management. Unfortunately, the small number of donor sites in the human body constitutes an absolute limit on the quantity of fresh autogenous cancellous bone available for filling a segmental defect. In addition, the donor sites are always a source of discomfort and morbidity for the patients. Intercalary defects resulting from trauma, infection or tumour can be treated with transport of a segment of bone within the limb using the Ilizarov technique. We report on three cases of local bone transportation for intercalary tibial defects by the Ilizarov method.

Chondro-epiphyseal separation of the distal humerus in the newborn. A case report and review of the literature.

Chondro-epiphyseal separation of the distal humerus is a rare injury, and when it occurs in the newborn, it may be difficult to diagnose and is easily mistaken for a dislocation of the elbow. The unimpressive clinical appearance of such an injury of the elbow in an infant, as well as the absence of ossific nuclei of the distal humerus in the newborn, are responsible for the dilemma in making the diagnosis. Ultrasonography, a readily available, non-invasive technique, can be used to evaluate the non-ossified epiphysis about the elbow of infants to demonstrate dislocations, fractures, and physeal separations. Closed reduction with or without percutaneous Kirschner wire fixation is the treatment of choice for these injuries. In this article, we report on a case of complete epiphyseal separation in a neonate and discuss the problems arising in its diagnosis.