Trauma of the wrist.

In wrist injury, plain radiographs form the basis of diagnostic imaging, and can provide definitive answers in most cases. MR imaging is the method of choice for several diagnostic problem cases. These problems can include radiographically occult fractures where MRI enables early diagnosis compared to follow-up radiographs. Early stage diagnosis of a post-traumatic avascular osteonecrosis with high sensitivity and specificity, is only possible with MRI. In these instances, radiographs are only sensitive in later stages and scintigraphy is quite nonspecific. Stress fractures, invisible with other modalities, are also demonstrable with MRI. In addition, MRI is helpful in special circumstances with regard to non-union or pseudarthrosis. In wrist instability, radiographs in combination with stress views and fluoroscopy are still the initial diagnostic step. MRI, with the advantage of direct visualization of the wrist ligaments and triangular fibrocartilage complex, offers very promising results in this area. Generally, for the evaluation of wrist injury, MRI can be considered the most important second-step procedure in patients where radiographs are nondiagnostic.

Rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: a multicenter analysis of 467 cases.

OBJECTIVE: A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails. DESIGN: Retrospective. SETTING: Four Level I trauma centers. PATIENTS: Four hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures. OUTCOME MEASUREMENTS: Clinical and radiographic analysis. METHODS: 467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio. RESULTS: Analysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent). CONCLUSIONS: Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p < 0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.

Displaced fractures of the proximal humerus in children require open/closed reduction and internal fixation.

Fractures of the proximal humerus in children are rare and constitute only 3% of all epiphyseal injuries. From 1992 to 2002 sixteen patients aged 4 - 15 years with a displaced fracture of the proximal humerus were treated at our level I trauma unit. The mean follow-up of the patients was 23.8 months (8 - 72). Ten children had a metaphyseal fracture and six a Salter and Harris Type II injury. Only one metaphyseal fracture was treated conservatively; the other patients underwent surgery (ORIF [= open reduction internal fixation] in ten patients, CRIF [= closed reduction internal fixation] in five patients). Follow-up examination showed no shortening or major angulation of the humerus in any of the sixteen cases. Fifteen children showed excellent and good results. There was only one average result in a polytraumatized child with additional injuries in both upper extremities. Based on the results of this study we suggest performing ORIF/CRIF in displaced fractures of the proximal humerus in children.

Occult fractures of the scaphoid. The diagnostic usefulness and indirect economic repercussions of radiography versus magnetic resonance scanning.

Scaphoid fractures that are not visible on initial radiographs are notoriously difficult to diagnose. This prospective study compared four-view plain radiography at an average of 14 days after injury, with high-definition macroradiography and magnetic resonance imaging at presentation. Initial magnetic resonance imaging was superior to repeat scaphoid radiography for the confirmation or exclusion of fractures as well as for the detection of associated wrist injuries. Macroradiography was unsuitable for screening for occult scaphoid fractures.

The effects of a prefeeding stimulation program on preterm infants.

OBJECTIVE: This study examined the effects of stroking and a perioral and intraoral prefeeding stimulation program on healthy, growing, preterm infants in a Level II special care nursery. Only infants without cardiac, gastrointestinal, or central nervous system problems were included in the study. METHOD: Two groups of nine randomly assigned, medically stable preterm infants, born between 30 weeks and 34 weeks gestation, were selected for the study. All infants were introduced to nipple feeding at approximately 34 weeks postconceptual age. The infants in the control group received a 5-min stroking protocol before feeding; the infants in the experimental group received a 5-min stroking protocol in addition to a perioral and intraoral stimulation program. RESULTS: Compared with the control group, the experimental group had a decreased number of gavage feedings, greater weight gain, and fewer days of hospitalization. The experimental group also had higher scores on the Revised-Neonatal Oral Motor Assessment nutritive suck scale than the control group. CONCLUSION: On a preliminary basis, the findings from this study establish the efficacy of occupational therapy in a Level II special care nursery for healthy, growing, preterm infants. Further, the specific treatment strategies conducted with the infants receiving the experimental procedures have also been preliminary established as effective in enhancing the infants' feeding skills, resulting in weight gain and decreased hospital stays as compared with their counterparts in the control group. However, our findings cannot be generalized to preterm infant populations who are at greater medical risk than the infants in our study because of the potentially hazardous effects that could result. Implications of the results for intervention programs and future research are discussed.

Measurement of ocular pursuits in normal children.

Ocular pursuits have been evaluated by occupational therapists (OTRs) in many settings, but normative information has been lacking. In this study, a standardized method of testing and recording ocular pursuits was developed and pilot tested on both normal and handicapped children. Normative data were then collected by using a cooperative research method in which 28 OTRs in the state of Colorado were trained, in a one-day workshop, to administer and score the test, achieving .98 inter-rater reliability for total test score. Each qualified tester evaluated approximately l5 normal children between 3 and ll years of age. The total sample was 489 subjects. There were some age-related trends, and most behaviors demonstrated a ceiling effect, particularly with older children. The results imply that many normal children have some immaturity in ocular pursuit skills until 6 or 7 years of age.

Reamed versus minimally reamed nailing: a prospectively randomised study of 100 patients with closed fractures of the tibia.

It is generally accepted that in tibial fractures the results of reamed intramedullary nailing are better than those of unreamed. However, it is not known whether the clinical effects of reaming are cumulative or if minimal reaming would induce the same beneficial effects as more extensive reaming. This international multicentre study has investigated the effects of different degrees of reaming. 100 patients with closed diaphyseal tibial fractures were prospectively randomised in two centres. Method of treatment was reamed nailing up to 12 mm inserting an 11 mm tibial nail (n: 50), and minimally reamed nailing up to 10 mm inserting a 9 mm tibial nail (n: 50). All patients included in the study had follow-up studies at 4,8,12,16,26 and 52 weeks after trauma. Sixty-six male and thirty-four female patients with an average age of 37.5 years were included in the study. Gender, age, and injury side were identical in both groups. There was no significant difference of complications in the two methods. The rate of deep wound infections was higher in the reamed group (n: 3) versus the minimally reamed group (n: 1). Union occurred earlier in the reamed group (17 wks) compared to patients with minimally reamed nailing (19 wks), and there were more patients with reamed nails in whom the fracture had healed by 16 weeks (57%) versus the minimally reamed group (43%), however, this was not statistically significant. Pain scales were similar for both groups from week 4 to week 52. A considerable number of outcome parameters including knee and ankle function, as well as the comparison of time intervals to restart certain activities, and return to work showed no significant statistical difference between the two groups. However, patients of the extensive reamed group returned earlier to running, training, and normal sports activities. This study found no significant evidence that more extensive reaming gave better results, however there seemed to be a tendency of more aggressive reaming to induce earlier fracture healing with a tendency of faster recovery times.

Percutaneous screw fixation versus conservative treatment for fractures of the waist of the scaphoid: a prospective randomised study.

We randomly allocated 60 consecutive patients with fractures of the waist of the scaphoid to percutaneous fixation with a cannulated Acutrak screw or immobilisation in a cast. The range of movement, the grip and pinch strength, the modified Green/O'Brien functional score, return to work and sports, and radiological evidence of union were evaluated at each follow-up visit. Patients were followed sequentially for one year. Those undergoing percutaneous screw fixation showed a quicker time to union (9.2 weeks vs 13.9 weeks, p < 0.001) than those treated with a cast. There was a trend towards a higher rate of nonunion in the non-operative group, although this was not statistically significant. Patients treated by operation had a more rapid return of function and to sport and full work compared with those managed conservatively. There was a very low complication rate. We recommend that all active patients should be offered percutaneous stabilisation for fractures of the waist of the scaphoid.

Ulnar procedures for post-traumatic disorders of the distal radioulnar joint.

Post-traumatic abnormality of the distal radioulnar joint (DRUJ) still presents a therapeutic challenge to orthopaedic surgeons. The most common difficulty is a failure to diagnose these injuries early, resulting in chronic post-traumatic disorders of the DRUJ. The main aim of therapy is to avoid adverse sequelae. This is of particular importance in malunion of the distal radius, the most common cause for post-traumatic disorders of the DRUJ. Distal radial malunion can be avoided by early appropriate treatment and the need for subsequent ulnar procedures reduced. Ulnar procedures for post-traumatic disorders of the DRUJ are intended to improve function and to decrease pain. Many methods to improve post-traumatic DRUJ function have been described. This article reviews the current state of the art in dealing with post-traumatic disorders of the distal radioulnar joint and presents algorithms to help in decision making.

[Vienna Shoulder Score (VSS) and Vienna Shoulder Formula (VSF) for follow-up and assessment of shoulder and shoulder girdle injuries]. / Vienna Schulter Score (VSS) und Vienna Schulter Formel (VSF) für die Nachkontrolle und Begutachtung von Schulter- und Schultergürtelverletzungen.

The Vienna Shoulder Score (VSS) was screened by two groups of patients for use in medical expertises and follow-up examinations. One group (n = 157) consisted of patients with healed clavicular bone fractures, the other group (n = 130) consisted of healthy individuals. The study proved that the VSS is a useful, exact and fast method of shoulder evaluation after injuries to the shoulder and shoulder girdle. The side dominance is of no influence to the outcome of the VSS. The Vienna Shoulder Formula (VSF) helps to equalize the age factor in shoulder examinations.

The fatigue strength of small diameter tibial nails.

This study was performed to evaluate the fatigue strength of commonly used small diameter tibial nails. Five types of small diameter tibial nails (7 mm aap Biorigid Nail, 8 mm aap Biorigid Nail, 8 mm Ace UTN, 8 mm RT Tibial Nail, 8 mm Synthes UTN) with a sample size of 30 implants (six samples of each nail type) were tested with a new modular testing system. One module of the testing system was removed, simulating a 55-mm distal tibial defect, to induce maximum loading on the distal portion of the implant and locking bolts. The average yield strengths were obtained from static, single cycle tests and revealed an average static ultimate load of 1072 N (aap7), 1820 N (aap8), 1812 N (Ace), 1942 N (R&T), and 1543 N (Syn). The fatigue limits were evaluated by cyclic, sinusoidal loading and revealed a fatigue strength of 750 N (aap7), 1092 N (aap8), 906 N (Ace), 971 N (R&T), and 771 N (Syn) to endure 500000 cycles. Our results showed that the solid tibial nails fractured in the testing device in the same manner and location as they do in the clinical series. This study showed that all the small diameter tibial nails tested are obviously able to transmit loads of more than average body weight. The fatigue strength of the implants is relatively high, which means that patients without bone defects could be mobilised with full weight bearing as tolerated by pain. However, according to the results of this study, early mobilisation with full weight bearing in a normal gait cycle can not be suggested in patients with segmental tibial fractures or fractures with defect zones.

Long-term results of pedicle stabilized thoracolumbar fractures in relation to the neurological deficit.

88 patients with thoracolumbar fractures and short-segment (mono or two segment) pedicle instrumentation from the years 1985-92 had a follow-up examination after an average time of 5.6 years. The 56 men and 32 women had an average age of 32.6 years at the time of injury, 24 patients primarily had a complete and 43 patients an incomplete paraplegia, 21 patients showed no neurological deficits. The operative decompression of the spinal cord and stabilization of the injured spine by short segment pedicle instrumentation led to a complete or partial remission of the neurological deficits in 93% of the patients with incomplete paraplegia. Operative stabilization allowed an early mobilization and rehabilitation of these patients. We found no tendency to an increased complication rate in patients with neurological deficits compared to patients without neurological deficits. Patients with initially incomplete paraplegia complained more often about pain than all the other patients. Despite intensive rehabilitation and retraining programs handicapped patients had obvious disadvantages regarding their further careers.

Predictive geometric factors in a standardized model of femoral neck fracture. Experimental study of cadaveric human femurs.

An experimental study was performed on 20 cadaveric human proximal femurs to investigate both the reproducibility of their mechanical behavior under uniaxial compression and the correlation of mechanical properties with geometric dimensions and bone density. These variables were assessed by radiography, physical measurement, and dual-energy X-ray absorptiometry (DEXA). The specimens were immobilized, loaded to the point of fracture, and analyzed with the help of a materials testing machine. The fractures invariably showed a similar pattern both in location (i.e. at the femoral neck) and in nature (i.e. "axial-shear" type according to the AO classification system). The mechanical properties of the tested proximal femurs correlated negatively with age (r = -0.39) and positively with sex (male femurs were stronger and correlated more closely than female femurs, P = 0.005). They showed a strong positive correlation with head diameter (r = 0.713, P = 0.0004), a moderate positive correlation with both neck axis length (r = 0.63) and neck diameter (r = 0.502), and a slight positive correlation with femoral neck-shaft angle (r = 0.326). All DEXA-based densitometry measures turned out to be powerful predictors of fracture force. The establishment of this solidly reproducible fracture model based on standardized loading conditions should have implications for future research on osteopenia/osteoporosis and preventive stabilization techniques.

Results of spinal cord decompression and thoracolumbar pedicle stabilisation in relation to the time of operation.

Short-segment pedicle stabilisation, transpedicular disc resection and autologous cancellous bone grafting is performed in trauma patients being transferred to our trauma centre with thoracolumbar fracture/dislocations. A follow-up examination of 88 patients, who were operated during the years of 1985-1992, took place after an average time of 5.6 years. Our results suggest that the earlier operative decompression and spine stabilisation takes place, the better is the recovery rate in patients with neurologic deficits. The highest neurologic recovery rates were found in patients operated within 8 h after the initial trauma. High remission rates were still found, if the patients had been operated within 48 h. After this time there was no significant difference in the neurologic outcome compared to the time of operation.

The standard Gamma nail: a critical analysis of 1,000 cases.

BACKGROUND: The continuous increase in the number of fractures of the proximal femur is directly attributable to the worldwide increase in life expectancy. The standard version of the Gamma Interlocking-Nail (standard Gamma nail [SGN], 200-mm length, 10-degree valgus curvature, two distal locking bolts) was designed because of the demands in orthopedic hip surgery to develop an implant stable enough to mobilize old patients as soon as possible to avoid further morbidity and mortality. METHODS: Between the years 1992 and 1998, 1,000 consecutive patients with peritrochanteric fractures were stabilized by using the SGN and included in this study. Special emphasis was given to the evaluation of the learning curve of the department of traumatology (not of single surgeons) and the influence of prognostic factors on the outcome of such operations. RESULTS: The results of this study show that increasing "department experience" resulted in a reduction of the intraoperative complication rate by a factor of 0.5 (p = 0.0001) per year. This means that even an inhomogeneous mass of 78 surgeons can lower the rate of intraoperative complications by 50% per year because of increased experience. The number of early postoperative complications annually decreased by a factor of 0.8 (p = 0.0042). CONCLUSION: Late postoperative complications correlate negatively with the patient's age (odds ratio, 0.9; p = 0.0001).

[Prospective comparison of MRI vs. direct magnification radiography in occult fractures of the scaphoid bone]. / Prospektiver Vergleich MRT vs. direkte Vergrösserungsradiographie bei okkulten Frakturen des Os scaphoideum.

The diagnosis of occult fractures of the scaphoid bone is even more challenging than that of conventional fractures of the scaphoid. This study aimed to compare prospectively the gold standard method (plain radiographs in four projections, after about 14 days) and the primary findings with direct magnification radiography (DIMA) and magnetic resonance imaging (MRI). Primary MRI showed much higher diagnostic power than plain radiography at 10-14 days in occult scaphoid fractures and in detection of associated carpal injuries. This may lead to a decreasing time of disease. DIMA was inferior in detecting occult fractures of the scaphoid.

Obturator prostheses after cancer surgery: an approach to speech outcome assessment.

PURPOSE: This article describes a speech assessment protocol for patients using either obturator prostheses or speech aid prostheses for surgically acquired defects due to cancer of the maxilla and/or soft palate. METHODS: This protocol is structured according to the executive summary of "Disability in America: Toward a National Agenda For Prevention" a report formulated by the Institute of Medicine that describes four levels of disorder: (1) pathology, (2) impairment, (3) functional limitation, and (4) disability. Assessment instruments included (1) the Sentence Intelligibility Test to measure the rate and understandability of speech, (2) a speech physiology system to measure appropriate separation of the nasal/nasopharyngeal and oral compartments, (3) a 13-point interval scale to rate speech nasality, and (4) a scale to rate self-perceptions of communication effectiveness. RESULTS: The results from two patients are reported to illustrate the outcome assessment protocol.

Unreamed nailing of tibial fractures with the solid tibial nail.

In 1993 a solid 7.5-mm tibial nail was developed and is composed of a wrought stainless steel alloy. In a preclinical testing series its static and dynamic mechanical properties proved to be superior to other small diameter nails. The clinical application of the Solid Tibial Nail in 70 cases of acute tibial diaphyseal fractures showed promising results. Neither severe intraoperative complications nor infections were observed. The entire series, including seven Grade I, eight Grade II, four Grade IIIA, and nine Grade IIIB open fractures, revealed a union rate of 95% at 6 months postoperative. After dynamization in one case and reaming and renailing in three cases, the fractures with delayed healing progressed to union within the following 3 months. There was no need for bone grafting in any of the cases. Locking screw breakage was observed in 10 (14%) cases 8 to 24 weeks postoperatively. This did not lead to any additional complications. No nail failures were observed. The excellent results of unreamed nailing with the Solid Tibial Nail consequently led to its use as the primary method of treatment for tibial fractures associated with soft tissue injury at the authors' institution.

Magnetic resonance imaging of occult scaphoid fractures.

Occult fractures of the scaphoid bone occur frequently and may lead to nonunions. In a prospective blind study, we performed magnetic resonance imaging (MRI) examinations on 32 patients who had sustained a wrist injury and in whom a scaphoid fracture was clinically suspected, but could not be confirmed on the original set of two routine and four scaphoid view radiographs. The MRI examinations were performed an average time of 2.8 days after the trauma. This prospective study proved that MRI is able to diagnose occult scaphoid fractures without delay and without the use of radioactive diagnostic means. Sensitivity and specificity of MRI were 100%. This conventional method could save $7,200 (US) per 100,000 inhabitants in providing an immediate and correct diagnosis and avoiding unnecessary cast immobilization. Additional injuries that may be misdiagnosed by conventional radiographs are also detected with a specificity and sensitivity of 100%.

Tracheobronchial ruptures in children.

Tracheobronchial ruptures in children after blunt trauma are rare, with an incidence at our clinic of 0.17% of juvenile thoracic injuries in the years 1985 to 1994. The symptoms are variable, and these injuries frequently occur in conjunction with other thoracic injuries, leading to delays in diagnosis. Diagnosis, conservative and operative treatment, and late complications are discussed by presenting four different cases of children with lesions of the tracheobronchial tree after blunt trauma.