Hemorrhage in pelvic fractures does not correlate with fracture length.

BACKGROUND: To analyze whether hematogenous marrow bleeding is the major source of hemorrhage after fractures of the pelvic ring. DESIGN: Retrospective cohort study. SETTING: Academic Level I trauma center. PATIENTS OR PARTICIPANTS: Three hundred seven consecutive pelvic ring injuries from January 1, 2000 to December 31, 2003 were evaluated. After exclusion for age, significant nonpelvic hemorrhage sources, and delayed transfer to this institution, 72 patients remained. MAIN OUTCOME MEASUREMENTS: Pelvic injuries were classified as fractures, fracture dislocations, or pure dislocations. These classifications were correlated to change in hematocrit between assumed preinjury and final hematocrit readings, correcting for blood transfused. RESULTS: The dislocation group had a greater change in hematocrit than the fracture group (2.1%), though not statistically significant. No significant correlations were found between change in hematocrit and length of fracture lines. CONCLUSIONS: Pelvic fracture surfaces may be sources of bleeding in pelvic injuries, but the fact that bleeding is similar in fractures and dislocations indicates fracture surfaces do not constitute the primary source. Based on our analysis one cannot reliably predict pelvic hemorrhage based on A/P radiograph assessments, such as fracture type.

Modified percutaneous needle aponeurotomy for the treatment of dupuytren's contracture: early results and complications.

BACKGROUND: The purpose of our study was to identify postoperative results and complications using a percutaneous approach to treat Dupuytren's contracture in a consecutive series of patients. METHODS: A review of all patients with Dupuytren's contracture treated with percutaneous needle aponeurotomy (NA) from 2008 to 2010 was performed. Patient demographics, digits affected, and disease severity was recorded. Pre-operative total passive extension deficit (TPED) was calculated for each affected digit. TPED in the immediate postoperative period and at the time of most recent follow-up was measured. Treatment-related complications and incidence of disease recurrence were identified. Statistical analysis was performed using paired t-test. (Statistical significance p-value <0.05). RESULTS: 525 digits in 193 hands were treated with NA. 140 patients were male, average age was 65 years. The average preoperative TPED was 41° and the average immediate postoperative TPED was 1° (98% correction) (P=0.0001). The average TPED at 4.5 month follow up was 11 o (73% correction). Complications included infection in 3 patients and one case each of triggering, delayed flexor tendon rupture, complex regional pain syndrome and persistent numbness. Recurrence was observed in 62 digits. CONCLUSION: Percutaneous needle aponeurotomy is an effective technique in the treatment of Dupuytren's contracture. Near complete correction of contracture was achieved and few complications were observed. Longer follow-up is needed to determine if these short-term results are maintained.

Kyphectomy in the treatment of patients with myelomeningocele.

BACKGROUND CONTEXT: Myelomeningocele kyphosis is a complex disorder that usually requires surgical intervention. Many complications can occur as a result of this disorder and its treatment, but only surgical correction offers the possibility of restoring spinal alignment. PURPOSE: The purpose of this retrospective study was to summarize the surgical results, complications, and short-term and midterm outcomes for surgical correction of severe kyphosis using a consistent surgical technique. STUDY DESIGN: This was a retrospective review of our database of pediatric patients with myelomeningocele and lumbar kyphosis who underwent kyphectomy with the use of the Warner and Fackler technique. PATIENT SAMPLE: Eleven pediatric kyphectomy cases performed by a single surgeon from 1984 to 2009 were reviewed. OUTCOME MEASURES: Outcome measures include imaging, kyphotic angle measurement, and physical examination. METHODS: Patients underwent the Warner and Fackler technique of posterior-only kyphectomy and bayonet-shaped anterior sacral fixation. RESULTS: The mean extent of kyphosis was 115.6° (range, 77-176°) preoperatively with a correction to 13.0° (range, 0-32°) postoperatively, and a reduction with an average of 102.6° (range, 65-160°), for an 88.7% correction. On an average, 2.0 (range, 1-6) vertebrae were resected. Immediately postoperatively and at follow-up, with an average of 67.2 months (range, 8-222 months), the average kyphosis angle was 13.0° (range, 0-32°). All patients undergoing the procedure were unable to lie supine preoperatively. All patients postoperatively could lie in the supine position. The functional outcome in patients and caretakers was rated very favorably because all patients and caretakers who provided feedback (9 of 11) reported that they were satisfied with the procedure and would undergo the procedure again if given the choice. CONCLUSIONS: This technique has become the most effective surgical reconstruction in myelomeningocele kyphosis. Although significant complications can occur during and after the procedure, most patients had satisfactory postoperative outcomes and restoration of sagittal balance with high patient and parent satisfaction.

Symptomatic coalition between the first and second metatarsals in a child.

Coalitions of the foot are relatively uncommon abnormalities, occurring in approximately 1% of the population. Talocalcaneal and calcaneonavicular are the most common types of coalitions. Coalitions in the forefoot, however, are rare, with only a small number of case reports in the literature. We report on a unilateral, symptomatic coalition between the first and second metatarsals in a 12-year-old girl who presented with a several-month history of intermittent medial-sided, dorsal forefoot pain and difficulty with shoe wear. Her preoperative examination was notable for a firm, nontender dorsal medial forefoot mass centered between the first and second metatarsals. While the first metatarsal head was level with the second metatarsal head in the sagittal plane, the metatarsals were rigidly fixed to one another. First metatarsal-medial cuneiform motion was reduced compared to the unaffected foot. Preoperative magnetic resonance imaging demonstrated a bony and cartilaginous coalition between the first and second metatarsals. Following resection, an immediate improvement was noted in motion between the first and second metatarsals, as well as the first metatarsal and medial cuneiform. In our patient, rigidity between the first and second metatarsals contributed to a stiff first ray with higher plantar pressures beneath the first metatarsal head with walking. The abnormal kinematics likely contributed to her medial forefoot pain with prolonged ambulation and sports activities. Prompt identification and resection of these less common coalitions affecting the forefoot allows symptomatic relief and restoration of normal kinematics.

Correlation of transfusion volume to change in hematocrit.

While it has generally been accepted that a 3% change in hematocrit is equivalent to a 1-"unit" loss of blood, few studies have been published to actually document this. A more complete understanding of this correlation would be helpful in estimating blood loss from changes in hematocrit in patients sustaining hemorrhage as well as in those receiving transfusions. In this retrospective study, we analyzed the post-transfusion alterations in hematocrit from 61 independent transfusions in 48 different pelvic fracture patients (age range, 16-62 years). Transfusion volumes were correlated with changes in hematocrit over 24-hr periods between the 5th and 12th hospital days, a time when there was no ongoing hemorrhage in these patients. The average increase in hematocrit per liter of packed red blood cells transfused was 6.4% +/- 4.1%. If 1 "unit" of packed red blood cells is approximately 300 mL, this becomes a change of hematocrit of 1.9% +/- 1.2% per "unit" of blood. The accepted correlation of about 1 "unit" of blood loss per 3% change in hematocrit would be valid for a 500-cc unit, but a typical unit of packed red blood cells is typically 300 cc. In addition, the variability is substantial as indicated by our standard deviation. Limitations of this study include hematocrit changes due to fluid resuscitation, dehydration, age, persistent hemorrhage, and the retrospective nature of the evaluation.