Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation.

PURPOSE: To evaluate healing rates and complications in patients treated with temporary external fixation (EF) and subsequent open reduction and internal fixation (ORIF) for high-energy distal femur or proximal tibia fractures. METHODS: Retrospective analysis of prospectively collected data 1999 to 2005. Demographic data and injury severity score were obtained from medical records. Factors reviewed included perioperative complications (nonunion, postoperative infection, loss of fixation) and time to radiographic and clinical union. RESULTS: Forty-seven patients with 16 distal femur and 36 proximal tibia fractures were treated using temporary EF. Patients subsequently underwent ORIF (mean time from EF to ORIF = 5 days, range 1-23 days). Thirty-five fractures were open (Gustilo I = 8, II = 6, IIIA = 3, IIIB = 13, IIIC = 5) and 17 closed. Forty patients with 44 fractures reached 1-year follow-up. Of these, 36 patients with 40 (91%) fractures had healed both radiographically and clinically. The mean postoperative follow-up time was 14 months (range 3-68). Eight (16%) deep infections occurred, all in open fractures (Gustilo I = 2, IIIB = 3, IIIC = 3), with one patient requiring above knee amputation. Other complications included one hematoma, two malunions, one fixation failure, and one pin site infection. One patient died as a result of a stroke. CONCLUSIONS AND SIGNIFICANCE: Temporary bridging EF offers the advantage of early soft tissue and bone stabilization without the potential local risks of immediate ORIF in severely injured soft tissues, or the potential systemic risks in a severely traumatized patient. The 16% infection rate in this study, all occurring in open fractures, falls within the reported range for grade III open fractures (15%-20%). We conclude that the initial treatment of high-energy periarticular knee fractures with bridging EF, followed by planned conversion to internal fixation is a safe option in patients who are unsuitable for initial definitive surgery.

The deltoid muscle: an anatomic description of the deltoid insertion to the proximal humerus.

OBJECTIVE: This study was designed to describe the anatomic insertion point of the deltoid to the proximal humerus. DESIGN: Gross anatomic study. SETTING: Level one academic trauma center. PATIENTS: Cadaveric study. MAIN OUTCOME MEASUREMENTS: Bilateral humeri were stripped of soft tissue except the deltoid insertion point. The length of the humeri was recorded. The distance from the greater tuberosity to the proximal most aspect of the tendinous insertion point and the distal most tendinous attachment was measured. The humeri were cross-sectioned 5-mm distal to the proximal insertion point, 5-mm proximal to the distal insertion point, and midway between these 2 points. The circumferential proportion of humerus into which the tendon inserted at each point was recorded. RESULTS: The mean length of the deltoid insertion was 97 (range, 83-111) mm. The mean distance from the greater tuberosity to the proximal insertion point was 61 (range, 55-75) mm and to the distal insertion was 158 (range, 142-172) mm. The deltoid occupied on average: 8% of the humeral circumference 5 mm from the proximal insertion point, 39% at the mid point of the insertion, and 31% of the humeral circumference 5 mm from the distal insertion point. CONCLUSIONS: The deltoid insertion is long and broad. A 4.5-mm plate would result in detaching 13.5 mm of the insertion, leaving at least half of the original insertion attached to the humerus.