Blood flow changes to the femoral head after acetabular fracture or dislocation in the acute injury and perioperative periods.

OBJECTIVES: Acute blood flow to the femoral head has been postulated to be affected negatively by traumatic acetabular fracture or dislocation. To the best of our knowledge, a prospective study that has examined acute changes in blood flow to the femoral head with respect to the timing of reduction and the effect of open reduction and internal fixation after acetabular fracture or dislocations has not been performed. DESIGN AND SETTING: From June 1994 to February 1996, fifty-four consecutive patients with hip dislocations with or without fractures of the acetabulum were entered into this investigation. The patients were categorized into three groups: isolated dislocations, fractures or dislocations requiring open reduction and internal fixation, and isolated acetabular fractures without dislocation but requiring open reduction and internal fixation. Single-photon emission computed tomography (SPECT) scans were obtained after relocations and preoperatively and postoperatively after open reduction and internal fixation of displaced acetabular fractures. RESULTS: The median dislocation time for all patients flow was 4.00 hours (range 1 to 24 hours). SPECT scanning showed a low blood flow pattern in five (9.25 percent) patients. A low blood flow pattern was seen in patients with early and late relocation times. Open reduction and internal fixation was not statistically associated with an avascular pattern of blood flow. Forty-two (78 percent) of our patients were available for follow-up, with an average of 24.3 months and a minimum of one year. There was one false-positive, one false-negative, and thirty-eight true-negative scans. CONCLUSIONS: A global loss of scintillation in the femoral head as determined by SPECT scanning occurs in some patients with hip dislocations and fractures or dislocations of the acetabulum in the early injury period. Changes in blood flow occurred in patients with short (one hour) and long (twenty-four hours) dislocation times. However, the development of avascular necrosis could not be predicted by early SPECT scanning. Until further multicenter studies are performed, SPECT scanning cannot be recommended on an acute or routine basis to predict those patients who will develop avascular necrosis. Operative approaches for open reduction of the hip and internal fixation of acetabular fractures do not appear to affect blood flow to the femoral head. Although a golden time to relocation cannot be fully established from this study, early relocation is advised to decrease the potential risk of vascular spasm, scarring, and subsequent avascular necrosis.

Traumatic arthritis of the hand and wrist in children.

Principles, and not established rules, form the basis for treating children with painful, posttraumatic arthritis involving the hand and wrist. The authors' preference is to exhaust nonoperative measures unless the involved joints are unstable or grossly incongruent. The authors would also recommend a greater degree of cautious observation in young children because of reports of successful outcomes associated with remodeling. Once surgery is necessary, the authors prefer motion-preserving procedures, bearing in mind that arthrodesis is well tolerated in the thumb interphalangeal joint and the finger DIP joints. Some authors have presented novel treatments, including complex microvascular reconstructions, but these authors recommend these procedures only in special circumstances, and only by physicians who are experienced with the techniques.

Shoulder reconstruction in patients with chronic brachial plexus birth palsy. A case control study.

Patients with chronic brachial plexus birth palsy and persistent peripheral neurologic deficits frequently have problems related to their shoulder. Specifically, internal rotation and adduction contractures develop because of the loss of muscle balance about the glenohumeral joint. With time, progressive and predictable deformity of the glenohumeral joint occurs. The authors reviewed their results in treating patients with persistent functional deficits with either soft tissue procedures (tendon transfers and muscle releases) or rotational humeral osteotomies based on criteria incorporating patient age and degree of glenohumeral deformity. Patients in each group were evaluated prospectively and compared with each other. In all cases, patients in both groups experienced substantial improvements in global shoulder function. In the patients in the tendon transfer group, global Mallet scores improved from an average of 9.5 to 15.6. Patients undergoing humeral osteotomies also had improvements in global Mallet score from an average of 9.5 to 15.1. This study confirms that both operations, when appropriately applied, will predictably improve shoulder function.

Ipsilateral femoral neck and shaft fractures.

Ipsilateral femoral neck and shaft fractures are uncommon injuries that present a surgical challenge. Patients are relatively young, are usually victims of high-energy trauma, and have frequently sustained multisystem injuries. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. This is important in light of the frequency of unrecognized ipsilateral femoral neck fractures. Several treatment options are described in the literature, but no clear consensus exists regarding the optimal treatment of these complex fractures. The authors contend that, given the potentially devastating complications of the femoral neck fracture in young patients (e.g., avascular necrosis, nonunion, and malunion), the neck fracture should be treated first and the shaft fracture second. The authors present an algorithm for the diagnosis and management of this injury based on a review of the literature, an understanding of the biology and severity of this injury, and the technical aspects of surgical treatment.