Tratamiento de las fracturas por herida de arma de fuego: revisión bibliográfica sistematizada / Treatment of gunshot wound fractures: systematic review of the literature / Tratamento de fraturas por arma de fogo: revisão bibliográfica sistematizada

Introducción: Las fracturas por heridas de arma de fuego son un motivo de consulta habitual en nuestro país. Existe gran variabilidad de conductas respecto a su tratamiento. El objetivo principal de este trabajo es analizar los distintos tratamientos y sus indicaciones. Materiales: Se realizó una revisión sistematizada de la literatura en las bases de datos Pubmed y Scielo. Se incluyeron artículos con fracturas por herida de arma de fuego en miembros superiores e inferiores, excluyendo la mano. Se analizó: tratamiento (ortopédico o quirúrgico), debridamiento, antibioticoterapia y complicaciones. Resultados: Se obtuvieron 19 artículos que cumplían los criterios de inclusión y exclusión. Los artículos tuvieron un Nivel de Evidencia tipo 2b, 3 y 4. Conclusiones: Los artículos analizados tienen un bajo nivel de evidencia. La fijación quirúrgica es variable y depende de la topografía ósea, la lesión de partes blandas y las lesiones asociadas. El debridamiento profundo está relacionado con mayores índices de infección. Las fracturas estables de tratamiento ortopédico no deberían debridarse ya que aumenta los índices de infección. Debería realizarse antibioticoterapia intravenosa inicial en todos los pacientes, la terapia posterior es discutida.

Introduction: Fractures due to gunshot wounds are a common reason for consultation in our country. There is great variability of conduct regarding its treatment. The main objective of this work is to analyze the different treatments and their indications. Materials: A systematic review of the literature was carried out in the Pubmed and Scielo databases. Articles with fractures due to gunshot wounds in the upper and lower limbs (excluding the hand) were included. We analyzed: treatment (orthopedic or surgical), debridement, antibiotic therapy and complications. Results: 19 articles were obtained that met the inclusion and exclusion criteria. The articles had a Level of Evidence type 2b, 3 and 4. Conclusions: The articles analyzed have a low level of evidence. Surgical fixation is variable and depends on bone topography, soft tissue injury, and associated injuries. Deep debridement is associated with higher rates of infection. Stable orthopedically treated fractures should not be debrided as this increases infection rates. Initial intravenous antibiotic therapy should be performed in all patients, subsequent therapy is discussed.

Introdução: As fraturas por ferimentos por arma de fogo são motivo comum de consulta em nosso país. Há grande variabilidade de conduta quanto ao seu tratamento. O objetivo principal deste trabalho é analisar os diferentes tratamentos e suas indicações. Materiais: Foi realizada revisão sistemática da literatura nas bases de dados Pubmed e Scielo. Foram incluídos artigos com fraturas por arma de fogo em membros superiores e inferiores, excluindo a mão. Foram analisados: tratamento (ortopédico ou cirúrgico), desbridamento, antibioticoterapia e complicações. Resultados: foram obtidos 19 artigos que atenderam aos critérios de inclusão e exclusão. Os artigos tinham Nível de Evidência tipo 2b, 3 e 4. Conclusões: Os artigos analisados ​​apresentam baixo nível de evidência. A fixação cirúrgica é variável e depende da topografia óssea, lesão de tecidos moles e lesões associadas. O desbridamento profundo está associado a maiores taxas de infecção. Fraturas estáveis ​​tratadas ortopedicamente não devem ser desbridadas, pois isso aumenta as taxas de infecção. A antibioticoterapia intravenosa inicial deve ser realizada em todos os pacientes, a terapia subsequente é discutida.

National trends in extremity fracture hospitalizations among older adults between 2003 and 2017.

BACKGROUND: Fractures in late life are highly consequential for health, services use, and spending. Little is known about trends in extremity fracture hospitalizations among older adults in the United States. DESIGN: Retrospective longitudinal cohort study. SETTING: The 2003-2017 National Inpatient Sample (NIS), a representative sample of U.S. community hospitals. PARTICIPANTS: Hospitalized adults aged 65 and older with a diagnosis of upper or lower extremity fracture. MEASUREMENTS: Incidence of extremity fracture hospitalization and mortality, using NIS discharge and trend weights, and population denominators derived from the U.S. Census Bureau. Incidence was reported separately for men and women by age, fracture diagnosis, and injury mechanism. Weighted linear regression was used to test for significant trends over time. RESULTS: Incidence of extremity fracture hospitalizations declined in both women (15.7%, p trend < 0.001) and men (3.2%, p trend < 0.001) between 2003 and 2017. This trend was primarily attributed to a decline in low energy femur fractures which accounted for 65% of all fracture hospitalizations. Among older adults with an extremity fracture hospitalization, mortality declined from 5.1% in 2003 to 3.3% in 2017 in men, and from 2.6% to 1.9% in women (p trend < 0.001). High energy fractures were due to falls (53%), motor vehicle accidents (34%), and other high impact injuries (13%). Overall, 12% of extremity fracture hospitalizations were attributed to high-energy injuries: increases were observed among men ages 65-74 (20%; p trend < 0.001) and 75-84 (10%; p trend = 0.013), but not among women of any age. CONCLUSION: Observed declines in the incidence of extremity fracture hospitalizations and related mortality are encouraging. However, increasing incidence of fracture hospitalization from high energy injuries among men suggests that older adults with complex injuries will be seen with more prevalence in the future.

Multidisciplinary management of the bone and joint infection complicating treatment of an open fracture of the lower limb.

Bone and joint infections (BJI) of the lower limb can cause functional sequelae and in some cases have an impact on patient's life prognostic. One of the main objectives of multidisciplinary consultation team meetings (MTM) in the treatment of bone and joint infections is to provide an appropriate medical-surgical care, pooling skills of different organ specialists: infectious disease physicians, microbiologists, orthopedic surgeons and plastic surgeons. Treatment is based on aggressive debridement, bone stabilization, adequate antibiotic therapy, long-term coverage of the loss of skin substance and close clinical monitoring. The authors present their multidisciplinary diagnostic and therapeutic approaches to BJI complicating an open fracture at a referent center in the management of complex bone and joint infections.

Using ultrasound to diagnose long bone fractures.

Point-of-care ultrasound may be an alternative to radiographs for diagnosing long bone fractures when medical resources are limited. Safe and timesaving, ultrasound also can be used in the ED as a screening tool for suspected long bone fractures and can detect associated musculoskeletal injuries. Ultrasound can be used in radiation-sensitive patients such as children and pregnant patients.Studies have found that clinicians using ultrasound can detect long bone fractures with an average 90% sensitivity and specificity after an average of 1 to 4 hours total of didactic and practical training. More research is needed to determine standards for ultrasound training, patient morbidity outcomes, cost effectiveness, and insurance benefits.

Risk Factors for Compartment Syndrome in Pediatric Trauma Patients.

OBJECTIVE: This study aimed to identify risk factors for compartment syndrome (CS) in pediatric trauma populations. METHODS: We included patients younger than 19 years treated at trauma centers contributing to the National Trauma Data Bank between 2009 and 2012. Multivariable logistic regression was used to examine the association between risk factors and the development of CS. The final model adjusted for age, sex, race, number of comorbidities, Glascow Coma Scale, Injury Severity Score, mechanism of injury, and fracture of the lower limb. RESULTS: A total of 341,238 patients were eligible for analysis, and 896 patients developed CS (0.3%). In adjusted regression models, older patients had significantly higher odds of CS compared with patients 1 years or younger (odds ratio [OR], 3.29 [95% confidence interval [CI], 1.29-8.37; 2-6 years]; OR, 7.55 [95% CI, 3.08-18.55 [7-12 years]; OR, 10.34 [95% CI, 4.26-25.09 [13-18 years]). Male patients had significantly increased odds of CS compared with female patients, as did patients with lower limb fractures compared with patients without lower limb fractures (OR, 1.93 [95% CI, 1.56-2.40]; OR, 7.61 [95% CI, 6.48-8.94]; respectively). Finally, patients with a firearm injury had higher odds of CS compared with other mechanisms of injury (OR, 3.51 [95% CI, 2.70-4.56]). CONCLUSIONS: Older pediatric trauma patients, male patients, and those with lower limb fractures and firearm injuries have increased odds of CS. Information on risk factors can be used to help identify patients most likely to develop CS, facilitating timely diagnosis and treatment.

Differentiation between perimortem trauma and heat-induced damage: the use of perimortem traits on burnt long bones.

Burnt human remains present a difficult interpretative dilemma to forensic pathologists and anthropologists. Distinguishing postmortem damage in long bones as a result of fire damage from perimortem fractures is an important challenge in trauma analysis. During our case investigation of a burnt body from a fiery car crash, distinct perimortem traits on long bone fractures were still distinguishable along the charred areas. Next to timing of fractures and shortening the perimortem time gap suggesting that the fractures occurred when soft tissue was still present, the traits make it possible to distinguish blunt trauma caused by the accident from heat-induced bone damage. Applying this specific perimortem pattern could be an additional macroscopic tool to interpret blunt force trauma more accurately in the analysis of burnt remains.

Update on leg fractures in paediatric patients.

Leg fractures are common and further increasing in prevalence in paediatric patients. The diagnosis is readily made in most cases. Choosing the best treatment is the main issue. Non-operative treatment is the reference standard for non-displaced or reducible and stable fractures but requires considerable expertise and close monitoring, as well as an immobilisation period that far exceeds 3 months in many cases. Some surgical teams therefore offer elastic stable intra-medullary nailing (ESIN) as an alternative to children who do not want to be immobilised for several months. Internal fixation is required for unstable or irreducible leg fractures. ESIN is often used as the first-line method, based on its very good risk/benefit ratio. For fractures that do not lend themselves to ESIN, optimal stabilisation can be achieved by choosing among the other available options (screw-plate fixation, rigid intra-medullary nailing or external fixation) on a case-by-case basis. Close monitoring during the first few days is crucial to ensure the early detection of compartment syndrome. The other complications and sequelae are non-specific.

Incidence, Costs and Predictors of Non-Union, Delayed Union and Mal-Union Following Long Bone Fracture.

Fracture healing complications are common and result in significant healthcare burden. The aim of this study was to determine the rate, costs and predictors of two-year readmission for surgical management of healing complications (delayed, mal, non-union) following fracture of the humerus, tibia or femur. Humeral, tibial and femoral (excluding proximal) fractures registered by the Victorian Orthopaedic Trauma Outcomes Registry over five years (n = 3962) were linked with population-level hospital admissions data to identify two-year readmissions for delayed, mal or non-union. Study outcomes included hospital length-of-stay (LOS) and inpatient costs. Multivariable logistic regression was used to determine demographic and injury-related factors associated with admission for fracture healing complications. Of the 3886 patients linked, 8.1% were readmitted for healing complications within two years post-fracture, with non-union the most common complication and higher rates for femoral and tibial shaft fractures. Admissions for fracture healing complications incurred total costs of $4.9 million AUD, with a median LOS of two days. After adjusting for confounders, patients had higher odds of developing complications if they were older, receiving compensation or had tibial or femoral shaft fractures. Patients who are older, with tibial and femoral shaft fractures should be targeted for future research aimed at preventing complications.

Segmental Additive Tissue Engineering.

Segmental bone defects caused by trauma and disease represent a major clinical problem worldwide. Current treatment options are limited and often associated with poor outcomes and severe complications. Bone engineering is a promising alternative solution, but a number of technical challenges must be addressed to allow for effective and reproducible construction of segmental grafts that meet the size and geometrical requirements needed for individual patients and routine clinical applications. It is important to devise engineering strategies and standard operating procedures that make it possible to scale up the size of bone-engineered grafts, minimize process and product variability, and facilitate technology transfer and implementation. To address these issues, we have combined traditional and modular tissue engineering approaches in a strategy referred to as Segmental Additive Tissue Engineering (SATE). To demonstrate this approach, a digital reconstruction of a rabbit femoral defect was partitioned transversally to the longitudinal axis into segments (modules) with discoidal geometry and defined thickness to enable protocol standardization and effective tissue formation in vitro. Bone grafts corresponding to each segment were then engineered using biomimetic scaffolds seeded with human induced pluripotent stem cell-derived mesodermal progenitors (iPSC-MPs) and a novel perfusion bioreactor with universal design. The SATE strategy enables the effective and reproducible engineering of segmental bone grafts for personalized skeletal reconstruction, and will facilitate technology transfer and implementation of a tissue engineering approach to segmental bone defect therapy.

Management of Lower Extremity Long-bone Fractures in Spinal Cord Injury Patients.

The AO classification system, used as a guide for modern fracture care and fixation, follows a basic philosophy of care that emphasizes early mobility and return to function. Lower extremity long-bone fractures in patients with spinal cord injury often are pathologic injuries that present unique challenges, to which the AO principles may not be entirely applicable. Optimal treatment achieves healing without affecting the functional level of the patient. These injuries often result from low-energy mechanisms in nonambulatory patients with osteopenic bone and a thin, insensate soft-tissue envelope. The complication rate can be high, and the outcomes can be catastrophic without proper care. Satisfactory results can be obtained through various methods of immobilization. Less frequently, internal fixation is applied. In certain cases, after discussion with the patient, amputation may be suitable. Prevention strategies aim to minimize bone loss and muscle atrophy.

[Influence on coagulation function and the therapy effect of damage control orthopaedics for unstable pelvic fractures and multiple fractures of extremities].

OBJECTIVE: To retrospectively explore the effects of damage control orthopaedics concept on coagulation and curative effects in unstable pelvic fractures and multiple fractures of limbs. METHODS: From March 2014 to December 2015, 40 patients with unstable pelvic fractures and limbs multiple fractures in treatment group included 22 males and 18 females with an average age of (39.00±4.12) years old were treated with the damage control orthopaedics concept, the ISS score was (25.36±10.81) on average;Other 40 patients with the same trauma in conventional group included 25 males and 15 females with an average age of (38.00±3.24) years old were treated with conventional method from January 2012 to January 2014 served as control, the average ISS score was 26.56±11.44. Matta criteria and Majeed function standard were used respectively to evaluate the fracture reduction and therapeutic effects postoperatively. Coagulation function on the 7th day postoperatively was compared between two groups. RESULTS: All patients were followed up for 6 to 24 months. According to Matta criteria, the fracture reduction of the treatment group and the conventional group were (7.38±5.09) mm and (10.11±6.53) mm, respectively (P<0.05). Majeed functional results of the treatment group and the conventional group were (86.12±6.84) points and (77.53±8.30) points, respectively (P<0.05). On the 7th day after surgery, PT, APTT, TT of the treatment group were significantly higher than that of the control group;and Fib of the treatment group was also significantly lower than that of the conventional group(P<0.05). CONCLUSIONS: The concept of damage control orthopaedics could effectively improve coagulation function of the patients with unstable pelvic fractures and limbs multiple fractures, thus are beneficial to the functional recovery as well as improve the curative effect postoperatively.

[The characteristic of the construction features of the power saw blades from the results of experimental studies of power saw injuries to the long tubular bones].

The objective of the present study was to elucidate the characteristic morphological signs of the power saw injuries to human long tubular bones and thereby make possible distinguishing between those inflicted by different types of power jigsaws. The experiments were carried out with the use of the power saws with high-speed reciprocating motion of the blade (power jigsaws and sabre saws). The study was focused on the experimental saw injuries to the human long tubular bones inflicted by the power jigsaws and sabre saws. The mathematical analysis has demonstrated the possibility of determining the properties of the saws and blades employed to inflict the injury based on the morphological and dimensional changes in the long tubular bones. The results of the study indicate that the forensic medical expertise of the injuries inflicted by power saws with high-speed reciprocating motion of the blade based on the morphological and dimensional changes in the long tubular bones makes it possible to identify with a probability of 98.6-99.7% both the construction and the size of the instrument used for sawing.

Pediatric Facial Fractures.

INTRODUCTION: There are few published articles describing the epidemiology of facial fractures in South Africa, and there is only one published study in pediatric patients. MATERIAL AND METHODS: This study retrospectively reviewed all medical records in a major metropolitan pediatric hospital in Cape Town, South Africa from September 2006 through May 2014. Inclusion criteria were children aged under the age of 13 with facial fractures. Fractures were assessed through head computed tomography (CT) scans. Patient's age, sex, cause of injury, general condition, existence of concomitant injuries, location of fractures, type of interventions, and length of stay were recorded and analyzed. RESULTS: A total of 53 men and 34 women were included in the study. Motor vehicle collisions (MVC) were the most common cause of facial fractures (56.3%). One hundred thirty facial fractures were presented on CT scans. The most common fractures in this study were mandible (43.1%). Comparing unrestrained motor vehicle collisions (UMVC) patients with those of other etiologies (OE), there was an increase in the average number of fractures (OE: 1.1, UMVC: 1.9; P < 0.0001), the average length of stay (OE: 4 days, UMVC: 9 days; P < 0.003), and the probabilities of sustaining concomitant injuries (OE: 31.0%, UMVC: 68.8%; P < 0.05) and requiring an operation (OE: 42.3%, UMVC: 81.3%; P < 0.01). DISCUSSION: This study establishes MVC as the most common etiology of facial fractures in South Africa. It demonstrates an increase in the complexity of facial injuries in unrestrained MVCs, suggesting the need for public awareness campaigns to install restraint devices in automobiles in South Africa.

Time Trade-Off as a Measure of Health-Related Quality of Life: Long Bone Nonunions Have a Devastating Impact.

BACKGROUND: Long bone nonunions have an important impact on a patient's quality of life. The purpose of this study was to compare long bone nonunions with use of the Time Trade-Off direct measure to compute utility scores and to determine which nonunion anatomic location had the lowest health-related quality of life. The Time Trade-Off assesses the percentage of a patient's remaining life that the patient would be willing to trade for perfect health. METHODS: Eight hundred and thirty-two consecutive long bone nonunions with Time Trade-Off data were identified and were retrospectively studied from a prospectively collected patient database. Nonunions with infections and those involving the articular portion of the bone were recorded. Time Trade-Off utility scores were obtained for all nonunion cases upon their initial clinical evaluation by a single surgeon specializing in reconstructive trauma. RESULTS: The mean utility score of our nonunion cohort was 0.68 and it differed significantly by long bone (p = 0.037). Nonunions of the forearm had the lowest utility score (0.54), followed by the clavicle (0.59), femur (0.68), tibia or fibula (0.68), and humerus (0.71). Post hoc tests showed that patients with nonunions of the forearm had significantly lower utility scores (p = 0.031) compared with all other bones. CONCLUSIONS: Patients diagnosed with a long bone nonunion have a very low health-related quality of life. We found that this single cohort's mean utility score was 0.68. This result is well below that of illnesses such as type-I diabetes mellitus (0.88), stroke (0.81), and acquired immunodeficiency syndrome (0.79). We found that patients with forearm nonunions had the lowest utility scores. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

[2014 literature findings in internal general medicine]. / Acquisitions thérapeutiques en médecine ambulatoire en 2014.

The usual treatment of venous ulcers may be associated with statins intake. Antibiotics have only marginal utility in acute bronchitis. The prescription of paracetamol seems to have no benefit in the treatment of acute lower back pain. The absence of antithrombotic prophylaxis for distal fractures of the lower limbs seems to be safe for patients' health. The treatment of atraumatic lesions of the rotator cuff in patients >55 years should remain conservative. Arthroscopic surgery of non-traumatic tear of the medial meniscus seems to have no benefit. The family environment seems to be a protective factor to the mental health of adolescents. Screening for colorectal cancer in patients >75 years would save lives.

Overuse lower extremity injuries in sports.

When athletes train harder the risk of injury increases, and there are several common overuse injuries to the lower extremity. Three of the most common lower extremity overuse injuries in sports are discussed including the diagnosis and treatments: medial tibal stress syndrome, iliotibial band syndrome, and stress fractures. The charge of sports medicine professionals is to identify and treat the cause of the injuries and not just treat the symptoms. Symptomatology is an excellent guide to healing and often the patient leads the physician to the proper diagnosis through an investigation of the athlete's training program, past injury history, dietary habits, choice of footwear, and training surface.

γ-Irradiation sterilized bone strengthened and toughened by ribose pre-treatment.

OBJECTIVE: This study tested the hypothesis that a ribose-based pre-treatment would protect the strength, ductility and toughness of γ-irradiation sterilized cortical bone. METHODS: Experiment 1: The effects of ribose pre-treatment (1.8M in PBS at 60°C for 24h) prior to 33 kGy of irradiation on strength, ductility and toughness (beams in three-point bending) and fracture toughness (J-integral at instability in single edge notched (bending)) were tested against matched non-irradiated and irradiated controls from bovine tibiae. Experiment 2: Three-point bending tests were conducted using beams from human femora (males, 59-67 years). Bone collagen thermal stability and network connectivity were examined using hydrothermal isometric tension testing. RESULTS: Ribose pre-treatment protected the strength, ductility and toughness of irradiation sterilized bovine and human specimens to differing degrees. Their ultimate strength was not detectably different from non-irradiated control levels; toughness in bovine and human specimens was protected by 57 and 76%, respectively. Untreated human bone was less affected by irradiation and ribose pre-treatment was more effective in human bone than bovine bone. CONCLUSIONS: This paper presents the first proof-of-principle that irradiation-sterilized bone with improved mechanical properties can be produced through the application of a ribose pre-irradiation treatment, which provides a more stable and connected collagen network than found in conventionally irradiated controls.

Venous thromboembolism associated with lower limb fractures after trauma: dilemma and management.

BACKGROUND: Trauma patients have the highest risk of developing venous thromboembolism (VTE) among hospitalised patients, with a reported 13-fold greater risk of developing VTE over non-trauma patients. This study examines the incidence of VTE and associated complications in trauma patients with lower limb fractures or injuries. METHODS: We retrospectively analysed 6,227 trauma patients and classified them according to injury severity score (ISS). The minor trauma group (ISS ≤15) contained 5,637 patients and the major trauma group (ISS >15) contained 590 patients. RESULTS: In the minor trauma group, VTE incidence was 1.17 %: 0.67 % were diagnosed with deep vein thrombosis (DVT) and 0.5 % with pulmonary embolism (PE). The readmission rate in the following 3-month period was 11 %, of which 2.8 % were subsequently rediagnosed with VTE. The 30-day mortality rate was 2.2 %. Seven patients died from PE following their initial admission and treatment, and another patient died from PE within three months after discharge. In the major trauma group, the VTE incidence was 6.8 %: 5.1 % with diagnosed with DVT and 1.7 % with PE. The readmission rate during the following three-month period was 6.6 %, of which 5 % were readmitted because of VTE and two cases were readmitted because of DVT. The overall 30-day mortality rate was 9.7 %, but no patients were formally diagnosed with a fatal case of PE. CONCLUSION: This study found that major trauma patients have an approximate six-fold increased risk of developing VTE during admission compared with minor trauma patients (relative risk: 5.79; 95 % confidence interval: 3.94-8.49). Our findings support the use of extended prophylaxis to treat minor trauma patients.