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Background: Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice., Methods: Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence., Results: Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing?, Conclusions: Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

Background: An earthquake occurred in Haiti on January 12, 2010. The center of earthquake and the most extensive damage occurred near the capital Port-au-Prince. There were an estimated 230,000 deaths with more than 250,000 others injured. The Israeli Defense Forces Field Hospital (IDF hospital) is a military unit composed of army-recruited (volunteer) medical personnel that was sent to Haiti to serve as a stand-alone center for early response until larger medical missions could become functional and take on the task of more sophisticated and long-lasting medical support. This study describes the use of external fixator frames for orthopedic damage control whereby bone stabilization in conjunction with soft tissue care serves as a stopgap until more comprehensive therapy is forthcoming., Methods: Data were collected from patients' files (generated at the IDF hospital) regarding the use and immediate outcome of limbs stabilized by external fixator frames., Results: During the 10 days of the IDF hospital's activity, a total of 1,111 patients were admitted; 244 surgical procedures were performed under general or regional anesthesia and of these, the orthopedists performed 221 (90%) surgical procedures. Seventy-three fractures were stabilized operatively by application of an external fixator. Most of the frames were applied on fractures (closed and open) of the lower limbs (48 on femur and 24 on tibia/fibula). All procedures were performed in a field-style operating room. Sterile technique was possible only for elements actually inserted into the patient. Limb alignment was based on manual palpation: intraoperative fluoroscopy was not available; soft tissue care followed bone stabilization. No patient died. All patients completed urgent stabilization at the IDF hospital and were transferred to other facilities or discharged for home care., Conclusions: We describe "orthopedic damage control" using external fixator frames for bone stabilization and soft tissue care as a viable approach in the context of a mass casualty scenario. Technical aspects are described in detail in addition to the advantages and limitations of this approach, which could serve as guidelines for future military and civilian scenarios where large-scale orthopedic damage control would be practiced.

Background: Traumatic sternal fractures occur in approximately 3% to 8% of all blunt trauma patients. Most of these fractures are treated conservatively, but a small number require operative intervention. Only a few studies have reported operative fixation of sternal fractures, and no investigation to our knowledge has systematically reviewed the literature on this intervention., Methods: We conducted a systematic review of the literature published from 1990 through September 2010 regarding the treatment of traumatic sternal fractures. We analyzed the available evidence regarding the surgical fixation of these fractures, the type of fixation used, the timing of the surgery, complications, and patient outcomes., Results: Twelve articles with 76 cases of surgically repaired sternal fractures met our study criteria. The indications for surgery, timing, and methods used for fixation were diverse. For instance, plates were used in 52 patients and wiring was selected in 24 patients for fixation. General and cardiothoracic surgeons treated the majority of sternal fractures requiring operative fixation. No serious postoperative complications were found in our review., Conclusions: Although the outcomes were generally positive, only one-half of the articles documented patient follow-up. In future studies, focus needs to be placed on long-term results and specific indications for surgery. The first step toward a standardized sternal fracture operative trial must be a prospective study of incidence and nonoperative long-term outcomes. It is likely that as the interest and demand for plate fixation increases, the demand for orthopedic involvement with sternal fractures will also increase.

Background: Open distal humerus fractures are associated with soft tissue and bony injury. This study compares the results of a staged protocol using initial joint spanning external fixation and delayed definitive fixation to acute definitive fixation., Methods: Treated open distal humerus fractures were retrospectively reviewed, with patients examined at 2 weeks, 6 weeks, 12 weeks, 26 weeks, and 52 weeks after definitive surgery. Outcomes were determined radiographically by union rate and clinically by range of motion, Short Musculoskeletal Function Assessment, Short Form-36, and Mayo Elbow Performance Index., Results: Fourteen treated patients with open AO/OTA type 13-C3 distal humerus fractures, with average patient age 52.7 years and average follow-up 98.6 weeks, were identified. All fractures were treated with initial irrigation and debridement emergently and either spanning external fixation in eight patients or primary definitive internal fixation in six patients. All fractures healed, with average time to osseous healing, in 25.7 weeks versus 23.4 weeks (p=0.7) in staged versus primary definitive treatment, respectively. Elbow range of motion on final follow-up was 73.75° versus 94.17° (p=0.22). Complications included nonunions, heterotopic ossification, infection, and persistent ulnar nerve deficit. Average functional outcomes scores for staged management versus primary internal fixation were Short Form-36, 50.2 versus 68.2 (p=0.065); Short Musculoskeletal Function Assessment, 33.5 versus 12.5 (p=0.078); and Mayo Elbow Performance Index, 55.6 versus 84.2 (p=0.011), respectively., Conclusions: Open distal humerus fractures had poor outcomes relative to normative functional scores; however, this is possibly due to more severe soft tissue injuries that were felt better managed with staged management at the time of presentation.

Background: Type and timing of treatment of femur fractures is controversial. Although reported as safe and effective in many reports, others have suggested that early definitive stabilization may cause complications, particularly in patients with chest and head injuries. Damage control orthopedics was proposed as an alternative in unstable patients. This study examines the effects of timing of fixation and investigates risk factors for complications., Methods: Seven hundred fifty patients with femur fractures treated between 1999 and 2006 were reviewed. Skeletally mature patients with mean age 35.8 years and mean Injury Severity Score (ISS) 23.7 were included. Four hundred ninety-two patients had ISS ≥18. Early stabilization (n = 656) was defined as definitive treatment of the femur fracture within 24 hours of injury., Results: Early definitive stabilization in patients with multiple injuries was associated with fewer complications than delayed stabilization (18.9% vs. 42.9%, p < 0.037) after adjusting for patient age and ISS. Early treatment was also associated with shorter hospital stay, intensive care unit stay, and ventilator days (p < 0.001). Severe (Abbreviated Injury Scale score ≥3) abdominal injury was associated with more complications than severe head (Glasgow Coma Scale score ≤8) and chest (Abbreviated Injury Scale score ≥3) injuries (44.2% vs. 40.9%, p = 0.68, and 34.4%, p = 0.024, respectively) and was an independent risk factor for complications (p < 0.0001). Chest injury was an independent risk factor for pulmonary complications (p < 0.001), but surgical delay in patients with chest injury was also associated with pulmonary complications (p = 0.04). More sepsis was noted patients with severe head injury (22.7% vs. 4.5%, p = 0.037) or severe chest injury (10.2% vs. 2.5%, p = 0.044) when treated on a delayed basis. More patients transferred from other hospitals were treated on a delayed basis (48.9% vs. 37.5%, p = 0.04)., Conclusions: Early definitive stabilization is associated with acceptably low rates of complications and is safe in most patients with multiple injuries, including some with severe abdominal, chest, or head injuries with attention to resuscitation before surgery. More complications and longer hospital stay were noted with delayed fixation after adjusting for age and ISS. Chest injury was associated with pulmonary complications; however, the presence of severe abdominal injury was the greatest risk factor for complications. Expediting access to definitive care may reduce complications and expenses.

Background: The value of cervical spine immobilization after penetrating trauma to the neck is the subject of lively debate. The purpose of this study was to review the epidemiology of unstable cervical spine injuries (CSI) after penetrating neck trauma in a large cohort of patients., Methods: This is a retrospective analysis of patients admitted with penetrating neck injuries to a Level I trauma center from January 1996 through December 2008. A penetrating neck injury was defined as a gunshot wound (GSW) or stab wound (SW) between the clavicles and the base of the skull. Univariate and multivariate analyses were performed to investigate associations between injury mechanisms, the presence of CSI instability, and mortality. Risk factors independently associated with the presence of a CSI were identified., Results: A total of 1,069 patients met inclusion criteria, of which 463 patients (43.3%) and 606 patients (56.7%) were sustaining GSW and SW, respectively. Overall, 65 patients (6.1%) were diagnosed with a CSI with a significantly higher incidence after GSWs compared with SWs (12.1% vs. 1.5%; p < 0.001). In four patients (0.4%), the CSI was considered unstable, all of them following GSW. All patients with unstable CSI had obvious neurologic deficits or altered mental status at the time of admission. Risk factors independently associated with the presence of a CSI were GSW to the neck and a Glasgow Coma Scale score ≤8 on admission (R = 0.16)., Conclusion: The overall incidence of unstable CSI after penetrating trauma to the neck is exceedingly low at 0.4%. Following GSW to the neck, an unstable CSI was noted in <1% of patients. After cervical SW, however, no spinal instability was noted precluding the need for spinal precautions in these instances.

Background: Closed suction drainage is a routine part of wound management for patients undergoing surgical treatment of acetabulum fractures. This pilot study seeks to determine if there is a difference in wound healing for a Kocher-Langenbeck approach with and without the use of drains., Methods: We conducted a prospective, randomized study including 39 patients with acetabulum fractures treated through a Kocher-Langenbeck approach. During wound closure, patients were randomized into two groups: 20 patients (group I) received drains and 19 (group II) were closed without drains. All were followed up for drain output, quality and quantity of drainage, signs of infection, and duration of drainage. Patients were then evaluated at 2 weeks and 8 weeks for wound healing and any signs of infection., Results: By the 8-week follow-up, all wounds healed without any signs of infection. There was no difference in the average number of days of drainage between groups: 7.45 days and 7.95 days for group I and group II, respectively (p = 0.37). There were two wound complications (5.13%), with one in each group. Both complications consisted of cellulitis without signs of deep infection and had complete resolution with intravenous antibiotics. A post hoc power analysis determined that a test population of 1,264 patients would be needed to show a reduction in wound drainage time by 1 day., Conclusion: With the numbers available in this pilot study, we showed no benefit to the use of drains for acetabular surgery performed through a Kocher-Langenbeck approach.

Background: The aim of the study was to determine the relative contributions to mortality of a unilateral or a bilateral femoral fracture in patients with or without injuries to other body regions., Study Design: An observational cohort study of the prospectively recorded England and Wales Trauma Registry data (Trauma Audit Research Network) from 1989 to 2003., Methods: Patients were divided into the following groups: UFi (isolated unilateral femur injury), BFi (isolated bilateral femur injury), and UFa and BFa, if an associated injury was present. Injury and treatment data were collected for each patient. Logistic regression data analysis was performed to determine variables that were associated with increased mortality., Results: Patients in group BFa had an increased mortality rate (31.6% vs. 9.8%) than patients in isolated bilateral femur injury group. Group BFa patients had an increased number of associated injuries (80%) than group UFa patients. Bilateral fracture, even in isolation, significantly increased the odds of mortality by 3.07. Intramedullary nailing was the method of fracture fixation associated with the lowest patient mortality overall. When assessing patient mortality in the BFa group with an New Injury Severity Score of >40, seven other fracture fixation regimens were associated with a lower mortality., Conclusions: The increase in mortality with BFs is more closely associated with the presence of associated injuries and poor physiologic parameters than with the presence of the BF alone. The presence of BFs should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential. Damage control fixation options should be considered in the subgroup with a very high New Injury Severity Score.

Background: The incidence of periprosthetic fractures after total knee arthroplasty is continuously rising because of an increasing number of knee joint replacements and an enhanced survivorship of the elderly population after knee arthroplasty. The purpose of this study was to analyze the practicability and effectiveness of the various treatment methods for management of periprosthetic fractures after total knee arthroplasty, and to determine the clinical and radiographic long-term results of patients following surgical and nonoperative treatment of these injuries., Methods: We reviewed the clinical and radiographic records of 41 patients (31 women and 10 men; average age, 78.6 years) with periprosthetic fractures after total knee arthroplasty between 1992 and 2008. Thirty-seven patients showed a periprosthetic fracture of the distal femur, and four patients had a periprosthetic proximal tibial fracture. Thirty-six patients underwent operative stabilization by plate fixation (n = 18), intramedullary nailing (n = 15) or revision arthroplasty (n = 3), and five patients were treated nonoperatively by long-term cast immobilization., Results: Twenty-eight patients returned to their preinjury activity level and were satisfied with their clinical outcome. In 10 patients, we saw a relevant decrease of knee function and severe limitations in gait and activities of daily living. Three patients died related to surgery. Successful fracture healing within 6 months was achieved in 33 (87%) of 38 patients. Failures of reduction or fixation occurred in 8 (21%) of 38 patients. Reoperation due to technical failures was necessary in three patients., Conclusions: Compared with current data in literature, we had a satisfactory outcome in following individualized treatment of periprosthetic fractures after knee joint replacement. Referring to the wide field of treatment options and high rates of complications, periprosthetic femoral fractures around the knee commonly constitute a challenging problem for the treating surgeons and require an adequate analysis of fracture etiology and a corresponding transfer into an individual treatment concept.

Background: The reported incidence of calcaneocuboid joint (CCJ) involvement in calcaneal fractures varies considerably. It is largely unknown to what extent CCJ involvement accounts for outcome in these fractures. Therefore, the goal of this study was to analyze the incidence and effects of CCJ involvement in calcaneal fractures., Methods: The clinical records of 106 patients, treated between 2000 and 2004, were reviewed for fracture classification, injury mechanism, surgical treatment, and complications. In a prospective cross-sectional study, 44 patients were assessed clinically (SF-36 American Orthopaedic Foot and Ankle Society score) and radiographically. Gait analysis was performed using dynamic pedography., Results: Sixty-eight percent of all fractures had involvement of the CCJ. Fractures with CCJ involvement were caused by a more severe injury than fractures without CCJ involvement (Mann-Whitney U test, p = 0.03); this is reflected by a strong association between CCJ involvement and fracture classification (Spearman, p < 0.006). Patients with involvement of the CCJ-especially those with a postoperative step in the CCJ-achieved a lower SF-36 score as well as a lower American Orthopaedic Foot and Ankle Society score than patients without CCJ involvement. CCJ involvement was associated with more difficulties in walking on rough surface (Spearman, p = 0.020). Limitations during gait were confirmed by dynamic pedography. Grading of posttraumatic osteoarthritis was associated with fracture classification (chi test p < 0.02) and quality of reduction (chi test p < 0.01)., Conclusions: These results indicate that calcaneal fractures with involvement of the CCJ are associated with more severe trauma and worse outcome. Thus, the CCJ should be given more credit during surgery and in our research efforts.

Background: Displaced tibial plateau fractures are traditionally treated with internal fixation using autologous bone grafting to provide structural support. In comminuted and osteoporotic fractures, there can be insufficient autograft available for this. Fresh-frozen bone allograft is readily available in sufficient quantity to fill all voids, is relatively inexpensive, and avoids donor site morbidity., Methods: We describe our technique and the early clinical and radiologic results of compaction morselized bone grafting (CMBG) for displaced tibial plateau fractures using fresh-frozen allograft., Results: This technique has been performed since July 2006 on eight patients. One patient died of an unrelated cause 3 months after surgery and one patient failed to attend follow-up clinic. Clinical and radiologic follow-up was performed on the remaining six patients at an average 15 months (range, 12-19) after surgery. One patient underwent a manipulation under anesthesia at 3 months for knee stiffness. One patient developed a painless valgus deformity and underwent a corrective osteotomy at 15 months. The height of the tibial plateau on radiographs has been maintained to an excellent grade (less than 2 mm depression) in all but one patient., Conclusion: CMBG using fresh-frozen allograft in depressed tibial plateau fractures provides structural support sufficient to maintain the height of the tibial plateau, is associated with few complications in complex patients with large bone loss, and has theoretical advantages of graft incorporation and remodeling.

Background: War-trauma, especially due to blast injury, can be associated with long bone fracture. Immediate external fixation of fractures, followed by internal fixation when the patient is medically stabilized (damage control orthopedics [DCO]), is the U.S. Army policy for war-related fractures. Data on infectious outcomes when DCO is used for war-trauma fractures are scant., Methods: A retrospective review of U.S. war-trauma patients from 2003 to 2007 with femoral or tibial fractures treated by DCO was conducted. Fisher's Exact and Mann-Whitney tests were used for comparisons., Results: Fifty-eight soldiers were identified. Fifty-five were males with a median age of 26 years (19-54 years) and a median time to internal fixation by intramedually nailing of 9 days (4-414 days). Eighty-eight percent of fractures were open, and 57% were femoral fractures. The median duration of follow-up was 447 days (20-1,340 days). Fracture site infection occurred in 40% (23 of 58), with suspected osteomyelitis in 17% (10 of 58). Of infected nails, fracture union occurred in 70% and nail retention in 57%. Median time to infection after nail placement was 15 days (0-717 days) with 75% of infections occurring by day 113. Multiple bacterial pathogens including Acinetobacter baumannii and Staphylococcus spp. were causative organisms. Blast injuries occurred in 91% of infected versus 47% of uninfected (p = 0.005). There was no difference between infections occurring in femoral (61%) versus tibial (39%) (p = 0.620) location., Conclusions: Infection was associated with 40% of DCO-associated intramedullary nails. Blast injury was a predictor of infection. Despite infection, fracture union and nail retention rates were high, suggesting a good outcome.

Background: Interactions between American and Dutch surgeons suggested differences in prescription habits for pain medication after fracture treatment., Methods: The percentages of 190 American [100 after hip open reduction and internal fixation (ORIF) and 90 after ankle ORIF] and 116 Dutch patients (69 after hip ORIF and 47 after ankle ORIF) receiving inpatient and outpatient prescriptions for narcotics were retrospectively compared between countries, to test the hypothesis that narcotics are prescribed more frequently in the United States as compared with The Netherlands after operative fracture treatment., Results: Among patients with hip fractures, 85% of American and 58% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 77% of American and none of the Dutch patients were prescribed narcotics (p < 0.001). The multivariate model including country accounted for 11% of the variation in inpatient narcotic prescription (p < 0.001), and the model including country and surgeon accounted for 55% of the variation in outpatient narcotic prescription (p < 0.001). Among patients with ankle fracture, 98% of American and 64% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 82% of American patients and 6% of Dutch patients were prescribed narcotics (p < 0.001). Predictors included country and surgeon and they accounted for 20% of the variation in inpatient narcotics prescription (p < 0.001) and 49% of the variation in outpatient narcotic prescription (p < 0.001)., Conclusions: American patients are prescribed significantly more inpatient and outpatient narcotic pain medication than Dutch patients after operative treatment of hip and ankle fractures.

Background: Endoscopic reduction has become common for reducing medial orbital wall fractures because of its various advantages. Nevertheless, there is no standard method of nasal packing to support the orbital contents to maintain the reduction. We evaluated the outcomes of endoscopic reduction of medial orbital wall fractures using the rolled Silastic sheet technique., Methods: Seventeen patients who underwent endoscopic reduction of medial orbital wall fractures were analyzed. They were diagnosed using 3-mm facial computed tomography and treated surgically under general anesthesia in our department between February 2006 and March 2008. Postoperatively, they were followed for at least 3 months., Results: The 17 patients comprised 13 men and 4 women ranging in age from 18 to 71 years (mean, 40.8 years). There were no significant intraoperative or postoperative complications. All 17 patients showed complete resolution of their symptoms after surgery., Conclusion: The technique using the rolled Silastic sheet for medial orbital wall fractures supports the safety and efficacy of endoscopic reduction.

Objective: The purpose of this study was to determine the incidence of deep venous thrombosis (DVT) in a prospective protocol of early spanning external fixation with the concurrent use of low-molecular weight heparin (LMWH) in patients with high-energy lower extremity trauma., Setting: Three level I trauma centers., Design: Prospective observational study., Patients: One hundred thirty-six consecutive patients with 151 complex lower extremity injuries were treated with a protocol of immediate joint spanning external fixation application and LMWH administration within 24 hours of admission. A total of 143 external fixators were applied. Early patient mobilization was encouraged and possible due to the skeletal stability provided by the external fixator. There were 87 men and 49 women with a mean age of 43 years. There were 62 proximal tibia fractures (Orthopaedic Trauma Association [OTA] Fracture Classification 41), 4 tibial shaft fractures (OTA 42), 49 distal tibia-fibula fractures (OTA 43, 44), 14 femur fractures (OTA 32, 33), 8 calcaneus fractures (OTA 73), 10 knee dislocations, and 4 talus fracture dislocations. Forty-eight injuries (32%) were open., Intervention: Temporary joint spanning external fixator placement, LMWH administration, and early mobilization within 24 hours of admission. Duplex ultrasonography of the bilateral lower extremities within 1 day to 3 days before fixator removal and definitive fixation procedure., Main Outcome Measurements: Presence of DVT on duplex ultrasound examination., Results: Duplex ultrasonography was negative for DVT in all but three patients for an incidence of 2.1% (3 of 143 fixators). There were no bleeding complications secondary to the use of LMWH while the temporary external fixator was in place., Conclusion: The incidence of DVT in patients treated with a protocol of early joint spanning external fixation and LMWH administration does not exceed historical controls. The early restoration of limb length, alignment, and stability allows early mobilization, which may contribute to the prevention of DVT.

Background: Fractures of the proximal and distal one thirds of the tibial shaft have historically higher malunion rates than those of the midshaft. This retrospective case series evaluates the postoperative radiographic outcome of intramedullary nailing of proximal and distal one-third tibial shaft fractures using intraoperative two-pin external fixation, often referred to as traveling traction., Materials and Methods: Between 2000 and 2005, 15 consecutive patients with proximal third and 27 consecutive patients with distal third displaced extra-articular fractures of the tibia were treated with statically locked intramedullary nailing and supplementary intraoperative two-pin rectangular frame external fixation. The external fixation was removed once the proximal and distal locking screws were in place. The alignment of the fractures was determined using standard postoperative anteroposterior and lateral radiographs., Results: Postoperatively, 14 of 15 patients with proximal fractures and 25 of 27 patients with distal fractures had less than 5 degrees of angular deformity in both the coronal and sagittal planes and less than 1 cm shortening., Conclusions: Statically locked intramedullary nailing with simultaneous intraoperative traveling traction external fixation as treatment for proximal and distal one-third extra-articular tibial shaft fractures is successful in achieving a high rate of acceptable postoperative alignment.

Background: Interlocking nailing is a standard procedure in the surgical treatment of tibial fractures. Despite it has been described to be a safe technique with excellent functional results compared with conservative treatment, a common problem is the development of anterior knee pain. The anatomic relation of Hoffa's fat pad with its nociceptors to the nail entry point has not been investigated, yet., Methods: Eighteen formalin-fixed lower cadaver extremities of 11 cadavers (five females, six males) were matched into three groups: three approaches (medial paratendinous, transligamentous, and lateral paratendinous) were performed and the anterosuperior tibial cortex was opened with a cheese cutter. To investigate the relationship of the nail entry point and Hoffa's fat pad, the joint capsule was incised, and Hoffa's fat pad was exposed and then dissected carefully. Damage to the fat pad was recorded as well as meniscal lesions, cartilage lesions, and ligamentous lesions. After full extension and flexion of the knee joint, the motion of Hoffa's fat pad (millimeter) was recorded with a measuring gauge. The zone for safe nail insertion (millimeter square) without any lesion to intra-articular structures was recorded., Results: Violation of Hoffa's fat pad was recorded if the lateral and transligamentous approach were used. With the medial approach, no damage of the fat pad was recorded. Total mean lateralization of the fat pad from extension to flexion over 90 degrees was 18.5 mm compared with its location in the fully extended knee. The safe zone for nail insertion without violation of menisci, cartilage, or ligaments was a triangle in the posteromedial aspect of the Hoffa with a mean dimension of 19.4 mm2., Conclusion: On the basis of our results, we can recommend the nail insertion via a medial paratendinous surgical approach to avoid injuries to the Hoffa fat pad and to menisci, cartilage, and ligaments.

Background: Iliac wing fractures have received little attention in the literature. Commonly occurring after a direct blow, they are rotationally and vertically stable. However, one must be aware of their potential for major morbidity including soft tissue, abdominal organ, and vascular lesions. This study examines the incidence, radiographic findings, soft tissue injuries, and complications associated with isolated iliac wing fractures., Methods: Retrospective review between 2003 and 2006 of a consecutive series of 450 polytraumatized patients treated in a level-1 University trauma center. Hospital charts and radiographs were reviewed and all patients with an isolated iliac wing fracture were requested to return for a clinical and radiologic examination., Results: One hundred twenty patients had major pelvic trauma. Only 10 sustained a fracture limited to the iliac wing, all after high-energy trauma. Nine of 10 patients sustained a total of 36 additional injuries involving head, thorax, spine, abdomen, urologic, and orthopedic systems. Only two patients underwent internal fixation of their fracture, one because of the fracture compressing the bowel and the other because of a very large rotated iliac wing fragment. Two patients with open fractures were treated with irrigation and débridement and no internal fixation., Conclusions: An isolated iliac wing fracture not compromising the stability of the pelvic ring may be interpreted as a benign injury. However, serious and potentially life-threatening associated injuries may be present requiring emergency abdominal, vascular, or neurologic surgery. A thorough search for such injuries is critical. Most iliac wing fractures can be managed nonoperatively.

Background: : We present an analysis of the prevalence of proximal humeral nonunions and an assessment of their functional outcome., Methods: : The results of a study of 11 proximal humeral nonunions taken from a previous prospective study of 1,027 consecutive proximal humeral fractures were analyzed to determine the demography of the patient population, the Constant and Neer scores at 6 weeks, 13 weeks, 26 weeks, and 1 year and the functional outcome of the patients. All patients had been followed for 1 year and standard anteroposterior and modified axial X-rays taken at each assessment. The possible factors associated with proximal nonunion were studied., Results: : The prevalence of proximal humeral nonunion is 1.1%, although it rises to about 8% if metaphyseal comminution is present and 10% if there is between 33% and 100% translation of the surgical neck. The effect of nonunion on function is considerable, even as early as 6 weeks after fracture. Our results show a deterioration of overall glenohumeral function after 6 months compared with patients whose fractures unite. Return to routine activities of daily living is markedly slower in the presence of a nonunion. The nonunions occurred in older patients but the age difference was not statistically significant., Conclusions: : Our results show that nonunion after nonoperative treatment of proximal humeral fractures is much less than has previously been reported and they suggest that age, metaphyseal comminution and fracture displacement are all factors in the development of nonunion. They also indicate that if operative treatment is required for proximal humeral nonunion it should not be delayed beyond 6 months after fracture and ideally should be performed as soon as the presence of a nonunion has become established this frequently being about 3 months after fracture.

Background: A novel rib fracture repair plating system was developed to provide durable fixation with a shorter length than standard systems and thus facilitate minimally invasive repair. We hypothesized that U-plate fixation would be at least equivalent in durability to standard anterior fixation., Study: Twenty fresh frozen ribs (10 pairs) from two human cadavers were first tested for intact stiffness (force or deformation). A gap of 5 mm was then created in the middle of each rib with a saw. Each rib was reconstructed with either the U-plate (4.6 cm length, Acute Innovations, LLC, Hillsboro, OR) with four screws or a 2.4-mm anterior locking plate (9.5 cm length, Synthes, Paoli, PA) with six screws. The U-plates were placed on one rib and the anterior plates on the contralateral rib of the paired levels. The reconstructed ribs were cycled 50,000 times with a load of +/-2N at 1 Hz in a simulation of the repetitive loading of deep breathing. The stiffness of the construct was measured throughout the test., Results: Stiffness decreased from the intact rib to the transected/plated rib for both types of fixation; however, a significant decrease in stiffness was observed only with the anterior repair (p = 0.03). After 50,000 cycles, the U-plated ribs lost 0.12 +/- 0.03 N/mm (1.9%) stiffness, whereas the anterior-plated ribs lost 0.72 +/- 0.13 N/mm (9.9%) stiffness (p = 0.001)., Conclusions: In this simulation of an unstable rib fracture with a small bony gap, U-plate fixation was more durable than standard anterior fixation. The greatly diminished size of the U-plate compared with the standard may facilitate minimally invasive rib fracture repair.

Background: Pin-track complications remain the most troublesome disadvantages of external fixation. The purpose of this study was to compare pin-related complications and pain levels after the use of external fixation for the stabilization of distal radial fractures with pins composed of two different materials., Methods: In a prospective trail 80 patients (320 pins) with unstable distal radial fracture were randomized for standard small AO-external fixator treatment with the use of identical pin geometry either composed of stainless-steel (Ss) (n = 40) or titanium alloy (Ti6Al4V) (n = 40). The patients were followed at biweekly intervals until the external fixators were removed (44 days after surgery). The patients were evaluated with regard to erythema, drainage, cellulitis, occurrence of pain at each pin-site, clinical or radiographic evidence of pin-loosening, the need for antibiotics, and the need for pin removal before fracture-healing due to infection., Results: The complication rate was 21%, and age was found to be significantly associated with an increased risk of pin-loosening (p = 0.003). There were no significant differences among the two groups with regard to the prevalence of pin-site complications. However, the rate of premature removal of fixator because of severe pin-track infection (5% vs. 0%) and the rate of pin-loosening (10% vs. 5%) was higher in the Ss-pin group. Furthermore, pain values were significantly reduced in the Ti6Al4V-pin group., Conclusions: The use of Ti6Al4V-pin external fixator in distal radial fractures yields a trend of reduced pin-related complications and significantly reduced pain levels than does the Ss-pin fixator.

Background: Although the use of a plate and bone graft is described as a well-known treatment for aseptic humeral shaft nonunion, unilateral external fixator can be alternative as a minimally invasive method. There has been no report comparing two methods of plate and external fixator for humeral shaft nonunion. Also, a few studies described humeral shaft aseptic nonunion treatment using unilateral external fixator., Methods: We retrospectively reviewed 31 patients (15 men and 16 women) with aseptic humeral shaft nonunion treated by plate (n = 20) and unilateral external fixator (n = 11). Patients were followed for a mean of 31.8 months. The right upper arm was involved in 19 patients (17 dominant) and left in 12 patients (2 dominant). The inclusion criteria were aseptic, middle shaft nonunion, without bone defects more than 2 cm. Four patients had hypertrophic, and 27 patients had atrophic nonunion., Results: Solid union, as documented on plain radiographic views, was obtained in 28 (90.3%) patients without additional operation. The average operative time was 92.8 minutes in plate group and 47.8 minutes in external fixator group (p < 0.05). The average blood loss was 142.5 mL in plate group and it was 45.5 mL in external fixator group (p < 0.05). Average hospital stay was 10.9 days in plate group and 3.9 days for external fixator group (p < 0.05). Overall, healing time in the plate group was 4.4 months, compared with 3.6 months in the external fixation group (p < 0.05). The mean Constant and Murley score for plate group was 85.6 points and it was 74.3 points for the external fixator group. According to Stewart and Hundley criteria, 16 (80%) patients in the plate group and 6 (54.5%) patients in the external fixator group had good outcome. Two-pin track infection of the external fixator (18.2%) and two transient radial nerve palsy (10%) were recorded., Conclusions: In this retrospective study of the humeral shaft nonunion, unilateral external fixator tended to yield equally favorable treatment results as did plate fixation. Advantages of the plate are good stability on the nonunion site and comfortability for patient. On the contrary, the advantages of the unilateral external fixator are minimal exposure to the nonunion site with minimal surgical trauma to the soft tissue, easy application of the fixator and consecutively minimal blood loss and short operative time. Unilateral external fixator could be a valuable alternative to plate fixation in aseptic humeral shaft nonunions.

Background: Operative fixation of rib fractures can reduce morbidity and mortality. Currently, resorbable fixation devices are used in a variety of surgical procedures., Methods: A standard osteotomy was prepared in 30 New Zealand white rabbits at the 12th rib. Eighteen had surgical repair with bioresorbable plates and 12 underwent nonoperative management. Half the animals in each group were killed at 3-week postfracture and the remaining animals were killed at 6-week postfracture. Ribs were radiographed and processed histologically to assess fracture healing. Rib reduction was defined as the alignment of the rib ends in a structural condition similar to the prefractured state and quantitative radiomorphometry measured the radiopaque callus surrounding the rib injury sites. Statistical analysis was performed using Fisher's exact test and an unpaired Student's t test and significance was established at p < 0.05., Results: At both the 3- and 6-week intervals, seven of the nine rib fractures remained reduced in the operative group, whereas zero of six and three of six of the rib fractures remained reduced, respectively, in the nonoperative group. A statistically significant increase in radiopaque callus surrounding the rib injury sites was observed at 3 and 6 weeks in the fixed groups., Conclusions: Fixation of rib fractures with a bioresorbable miniplate system was superior to nonoperative treatment at the 3-week interval, with a statistically significant increase in radiopaque callus formation at both 3 and 6 weeks. Additional studies will evaluate the biomechanical outcomes and degradation tissue response after extended in vivo intervals.

Purpose: To compare the stability of a novel, nonspanning external fixator with a standard volar locked plate for treatment of unstable distal radius fractures., Methods: A simulated, unstable, extra- articular distal radius fracture was created in six matched pairs of fresh frozen human distal radii. One of each pair was treated with a nonspanning external fixator [Mirza Cross Pin Fixator (CPX), A.M. Surgical Inc. Smithtown, NY] and the other was treated with a volar locked plate [Distal Volar Radial Plate (DVR), Hand Innovations, Miami, FL]. Each specimen was axially loaded in central, dorsal, and volar locations, loaded in cantilever bending in volar to dorsal, dorsal to volar, and radial to ulnar directions and loaded in torsion. Load-displacement curves were generated to determine the construct stiffness for each loading schema, with comparisons made between the two treatment groups. Specimens were then cyclically loaded with 50 N axial loads applied for 1,000 and 10,000 cycles. Measurement of construct stiffness was repeated and comparisons made both between the two treatments and within treatments to their precycling stiffness., Results: There was no significant difference in the mechanical stiffness of the nonspanning external fixator and the volar locking plate after axial loading in any of the loading modalities. Cyclic loads of 1,000 and 10,000 cycles resulted in no significant difference in construct stiffness between the nonspanning external fixator and volar locked plate. However, the nonspanning external fixator demonstrated decreasing stiffness after cyclic loading with 10,000 cycles (p < 0.02)., Conclusion: This study demonstrated no significant difference in the mechanical stiffness of the CPX nonspanning external fixator and volar locked plate in a cadaveric fracture model. Both constructs appear to be biomechanically equivalent in this experimental model; however, this is only one factor in the choice of fixation device for the management of unstable distal radius fractures.

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.

Background: Shortening of the femoral neck after fracture fixation with multiple parallel screws decreases the moment arm for the abductor muscles of the hip. This study aimed to assess the incidence of femoral neck shortening quantitatively and qualitatively in patients with femoral neck fractures treated with multiple cannulated screws, and to investigate its influence on functional outcome., Methods: We conducted an observational study in a consecutive series of 56 patients with united fractures of the femoral neck treated with multiple cancellous screws. The latest anterior-posterior radiograph of the fractured hip was compared with that of the contralateral uninjured hip. After scanning and electronically overlapping those radiographs, femoral neck shortening was assessed. All identified patients were contacted and the Short Form-36 (SF-36) functional outcome questionnaire was administered., Results: The shortening rate was 31% for undisplaced (14 of 45) and 27% for displaced fractures (3 of 11). The average abductor moment arm shortening was 10 +/- 4 mm. The average femur length decrease was 8 +/- 5 mm. In all other patients, abductor moment arm as well as femur length measurements were within 3 mm of the contralateral side and considered not to be shortened. Thirteen patients completed the SF-36 questionnaire (12 of 13 undisplaced fractures; all 13 with good fracture reduction). Patients with shortened fractures (8 of 13) had significantly lower Physical Functioning (p = 0.01) and Role Physical (p = 0.04) SF-36 subscores., Conclusions: Femoral neck shortening after femoral neck fracture fixation with multiple cancellous screws is common and it has a significant negative impact on physical functioning.

Background: We intended to evaluate the technique of treatment of complex fractures of the tibial plateau using external circular fixation combined with limited internal fixation, and to evaluate the treatment outcomes., Methods: From 1992 to 2002, we treated 59 patients (40 men, 19 women) ranging in age from 23 to 63 years with the external circular fixation. All the cases were classified preoperatively as Schatzker types V, VI/Orthopedic Trauma Association 41-C1.3, C2.3, C3.1, C3.3. Five fractures were open. Three different strategies of treatment were used: (1) the frame is confined to the tibia when the external fixation is stable enough to allow knee bending; (2) the frame is extended onto the distal femur, with the proximal tibial ring located at the level of the tibial plateau when the joint surface is severely unstable; and (3) the frame is extended onto the distal femur, with the proximal tibial ring located more distally, bypassing the fracture, when the skin and soft tissue are compromised and within the fracture there is no bone suitable to place wires and pins for the external fixation construct., Results: The results were evaluated as excellent in 30 patients (50.85%), good in 27 patients (45.76%), fair in 1 patient (1.695%), and poor in another 1 (1.695%). The patients' satisfaction was significantly related with the functional results., Conclusions: Our hybrid Ilizarov method combined with minimal internal fixation enables excellent to good results in most cases of complex tibial plateau fractures.

Objective: To study the functional outcome of displaced distal radius fractures treated by open reduction and internal fixation with the use of fragment-specific fixation., Methods: Fifteen consecutive displaced distal radius fractures (5 extra-articular and 10 intra-articular) were treated using the Trimed distal radius fixation system (Trimed, Valencia, CA). Radiographic assessment and range of motion of the affected wrist were evaluated postoperatively. Functional outcomes were evaluated with use of the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Gartland and Werley scoring system., Results: The mean follow-up was 11 months. The patients initiated controlled passive and active motion exercises during the first week. The mean score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 16 points. The mean return to work was 12 weeks. The functional outcome was 80% excellent or good by the Gartland and Werley scoring system for intra-articular fractures and 80% excellent for extra-articular fractures. Range of active motion in intra-articular fractures was measured 60 degrees wrist extension, 64 degrees flexion, 65 degrees pronation, and 70 degrees supination, and for extra-articular fractures, 75 degrees extension, 70 degrees flexion, 80 degrees pronation, and 75 degrees supination. There was failure of fixation with loss of the reduction that was achieved at the time of operation in one patient., Conclusions: Fragment-specific fixation of unstable distal radius fractures using the Trimed system appears to be effective. Anatomic reduction, earlier range of motion, and improved functional results can be achieved using low-profile implants.

Background: The healing of a metaphyseal fracture line is a major problem in cases of distal tibial fracture treated with external fixation., Methods: Forty-seven distal tibial fractures treated with two-ring Ilizarov hybrid external fixation (16 AO/OTA type A and 31 type C, 10 open) were followed up. Fracture reduction and union time was evaluated and IOWA and RAND 36-Item Health Survey scores were used to assess functional outcome., Results: Thirty-five fractures united uneventfully in a median time of 20 weeks, but 12 fractures needed additional procedures because of delayed union. According to univariate analysis, the risk factors for a longer time needed for fracture union were translational displacement and current smoking, and the risk factors for reoperation because of delayed union translational displacement fibular fracture fixation, and the number of cigarettes smoked per day. In multivariate analysis, translational displacement was a risk factor for both longer time to fracture union and reoperation and fibular fracture fixation was a risk factor for reoperation. If the translational displacement was less than 3 mm, the reoperation rate was 6%, whereas if the displacement was more than 3 mm, it was 83%. Reoperation was performed on 50% of the patients who underwent fibular fixation and on 15% of the patients who did not undergo fibular fixation. There were only marginal decreases in the range of motion and arthritis scores in the AO/OTA fracture types other than type C3. There were no significant differences in RAND 36 scores between the general Finnish population aged 18 to 64 years and our patients., Conclusions: Hybrid external fixation of distal tibial fractures is associated with delayed union, which is closely related to the degree of residual translational displacement after reduction. Fixation of an associated fibular fracture does not help to achieve better contact in the tibial fracture and increases the risk of delayed union.

Background: The purpose of this study was to evaluate if there is a difference in the rates of infection between Ilizarov wires and half-pins and between half-pins with threads outside and inside the skin in circular fixators modified by Catagni and Cattaneo., Methods: Between May and December 2004, 218 patients with circular Ilizarov fixators for various orthopaedic indications who visited our Ilizarov clinic were subjected to a one-time evaluation of half-pins and wires., Results: A total of 1,093 half-pins were checked and 34 (3.11%) of these were infected (50% with threads outside and 50% with threads inside the skin). Among a total number of 951 wires (1,092 pin tracts) checked, 45 (4.73%) were infected., Conclusions: We conclude that the circular Ilizarov fixation with conical half-pins and wires has similar rate of infection compared with conventional Ilizarov circular fixator. Moreover, there is no difference in infection rates between pins with threads inside the skin as compared to those with threads outside the skin.

Background: Completely round nails, in contrast to conventional locked nails with surface grooves, for postoperative endosteal revascularization may increase the nail rigidity and decrease the manufacture cost. Both-ends-threaded screws with higher fatigue strength require smaller nail holes and can further increase the mechanical strength of the nails., Methods: In this study, both-ends-threaded locking screws were used to treat 68 tibial fractures, including 56 acute fractures in 54 patients and 12 nonunions in 12 patients. There were 41 men and 25 women with a mean age of 39.6 years, and the average follow-up was 24 months. For acute fractures, there were 11 type I, 9 type II, 5 type IIIA, and 3 type IIIB open fractures. Acute fractures were treated with closed nailing. Five hypertrophic nonunions were treated with closed exchanged nailing, and seven oligotrophic nonunions were treated with open nailing and iliac bone grafting., Results: With a single nailing procedure, 53 acute fractures and all nonunions achieved union with mean times of 17.4 weeks and 18.4 weeks, respectively. Three patients underwent exchange nailing and bone grafting and had eventual fracture union. Three fractures with compartment syndrome were treated with fasciotomy. Deep infection occurred in two open fractures but was successfully treated. Nail breakage occurred in one distal fracture and screw backout occurred in another, but fracture union was not affected. Recovery of joint motion was essentially normal in patients without knee or ankle injury., Conclusions: This study showed that completely round nails with both-ends-threaded locking screws could effectively treat tibial fractures. Completely round nails have the advantages of high mechanical strength and low manufacturing cost.

Background: Changes in compartment pressures have been noted during traction, reduction, and intramedullary fixation of fractures. Changes in limb length and compartment volumes are suspected contributing factors. Pressure and volume changes are known to be related in animal models. If an acute increase in limb length can adversely affect compartment pressures, reversal or delay of such an increase in length may be of value in the treatment and prevention of compartment syndromes., Methods: A clinical example is presented in which a documented anterior compartment syndrome was successfully treated by deliberate loss of fracture reduction, without fasciotomy. Fracture reduction was later restored when swelling subsided. Anterior compartment pressures were recorded in response to limb length changes in osteotomized cadaver limbs stabilized with external fixation., Results: The pressure in the anterior compartment varies directly with acute changes in the length of the leg, in an experimental model. Mathematical analysis indicates that available volume within a compartment varies inversely with acute changes in its length., Conclusions: Fracture reduction that restores the length of an acutely injured extremity may increase pressure in the compartments by decreasing available volume. Deliberate loss of reduction can decrease pressure in the compartments, offering a potential alternative to fasciotomy in the care of compartment syndrome in cautiously selected, monitored patients. Early stabilization without reduction, followed by delayed reduction, may be preferable during treatment of fractures prone to compartment syndrome. Decreased available compartment volume may contribute to compartment syndrome after distraction with intramedullary rods or skeletal traction.

Background: Pelvic ring injuries are associated with a high incidence of mortality mainly due to retroperitoneal hemorrhage. Early stabilization is an integral part of hemorrhage control. Temporary stabilization can be provided by a pelvic sheet, sling, or an inflatable garment. However, these devices lack control of the applied circumferential compression. We evaluated a pelvic circumferential compression device (PCCD), which allows for force-controlled circumferential compression. In a prospective clinical trial, we documented how this device can provide effective reduction of open-book type pelvic injuries without causing overcompression of lateral compression type injuries., Methods: Sixteen patients with pelvic ring injuries were enrolled. Pelvic fractures were temporarily stabilized with a PCCD until definitive stabilization was provided. Anteroposterior pelvic radiographs were obtained before and after PCCD application, and after definitive stabilization. These radiographs were analyzed to quantify pelvic reduction due to the PCCD in comparison to the quality of reduction after definitive stabilization. Results were stratified into external rotation and internal rotation fracture patterns., Results: In the external rotation group, the PCCD significantly reduced the pelvic width by 9.9 +/- 6.0%. This reduction closely approximated the 10.0 +/- 4.1% reduction in pelvic width achieved by definitive stabilization. In the internal rotation group, the PCCD did not cause significant overcompression. No complications were observed., Conclusions: A PCCD can effectively reduce pelvic ring injuries. It poses a minimal risk for overcompression and complications as compared with reduction alternatives that do not provide a feedback on the applied reduction force.

Background: To determine the prognosis of fractures of the mandibular condyle after closed treatment., Methods: Patients (n = 144) with a fracture of the mandibular condyle, all treated closed, were included in the study. Fracture types and position of the fracture parts were determined on radiographs. Follow-up was after 12 months in which the average pain, experienced during the last week (visual analog scale, 100 mm), and mandibular functioning were assessed (mandibular function impairment questionnaire (MFIQ))., Results: Data of 116 (81%) patients, 41 women (35%) and 75 men (65%), were available for analysis. Condylar neck fractures were most common (52%). Bilateral fractures were present in 28% of the patients. Pain (visual analog scale score >0) was found in 9% of the patients. Impaired mandibular function was found in 40% (MFIQ >0) and 24% (MFIQ > or =4) of the patients. The most important risk factor for pain was being a woman. The most important risk factors for function impairment were > or =25 years of age and gross displacement of the fracture parts., Conclusion: The overall prognosis of mandibular function and pain after closed treatment of condylar fractures is good. The most important risk factor for pain persisting for 1 year after closed treatment of a condylar fracture is being a woman. The most important risk factors for function impairment are an age of > or =25 years and gross displacement of the fracture parts.

Background: Most children with humeral supracondylar fractures can be treated with simple closed reduction and cross-fixation with Kirschner (K)-wires. However, in a small proportion of cases, an acceptable closed reduction cannot be obtained, and open reduction becomes necessary. An alternative to open reduction is the use of a temporary 3-mm K-wire to manipulate and reduce the distal fragment. This report introduces the method of manipulation, as well as indications, and draws comparisons with complete close reduction cases., Methods: Of 118 patients, 76 (64.4%) were managed with the standard closed reduction method and additional K-wire fixation to secure a good alignment (group 1). In the remaining 42 cases (35.6%), acceptable reduction could not be achieved by closed methods alone, and another temporary 3-mm K-wire was used to manipulate the distal fragment. After reduction of the fracture with the additional wire, standard cross K-wires were inserted to stabilize the fracture (group 2). As long as there was contact at the fracture site in cases of humeral supracondylar fracture, the traditional closed method was used easily to achieve excellent restoration. However, for cases in which the fracture site was totally displaced, and contact at the fracture site via traction was unsuccessful, a 3-mm K-wire was used to perform supplemental restoration treatment. All the patients, after the operation, were temporally immobilized with a long-arm splint for about 3 weeks. The fixation K-wires were removed after the radiograph had shown callus formation over the fracture site. Then the operation indications, operation methods and time, complications, and differences in range of motion were analyzed for these two sets of patients., Results: The average group 1 surgery time was 18 minutes (range, 9-32 minutes), whereas the average surgery time for group 2 was 33 minutes (range, 15-45 minutes). Three cases in group 1 were complicated with ulnar nerve injury caused by the fixation wire. There were no ulnar nerve injuries in group 2. However, the ulnar nerve injury complication rates for the two groups (3 in 76 for group 1; 0 in 40 for group 2) did not reach statistical difference (p = 0.5502, Fisher's exact test). The union times for the two groups were almost the same (average, 3 weeks; range, 2-5 weeks). The 3-mm K-wire manipulation reduction cases and the closed reduction cases seemed to yield the same healing results in all aspects, except for the longer surgery time in group 2 (p < 0.0001). Both groups achieved satisfactory results., Conclusions: The closed reduction method should be used for children with humeral supracondylar fractures, whenever possible. The 3-mm K-wire manipulation method reduces the probability that open reduction will be required in some severe cases. This is a simple method without complications. The prognosis is the same as for closed reduction cases.

Background: Rapid diagnosis of scaphoid bone fracture in the wrist is important so that appropriate treatment can be started. If a fracture is clinically suspected without being visible on radiography, further investigation has to be conducted to reveal a fracture or to rule it out. The objective of this study was to investigate the validity of computed tomographic (CT) scanning and bone scintigraphy compared with the clinical fracture rate during follow-up of 1 year for examining patients with a suspected scaphoid fracture., Methods: Bone scintigraphy and CT scanning were performed in 29 patients with persistent clinical suspicion of a scaphoid bone fracture 5 to 10 days after trauma., Results: The sensitivity, specificity, and positive and negative predictive values of the CT scan were 100%. The sensitivity, specificity, and positive and negative predictive values of bone scintigraphy were 78%, 90%, 78%, and 90%, respectively. Seven patients showed a fracture on both CT scanning and bone scintigraphy. Eighteen patients showed no fracture on both CT scanning and bone scintigraphy. A false-positive bone scintigram showed up in two patients and a false-negative bone scintigram in another two patients., Conclusion: CT scanning is a rapid, simple, valid method for demonstrating or ruling out a scaphoid fracture and is superior to bone scintigraphy.

Background: The assessment of the sternal fracture and concomitant injuries is discussed., Methods: Two hundred sternal fractures were analyzed with respect to accident circumstances, fracture morphology and topography, and associated injuries., Results: Traffic accidents were frequent; 89.2% of them were motor vehicle crashes of restrained passengers, 76.5% of fractures were localized in the corpus sterni, and 8.5% of the injuries resulted in fractures or complete disruptions of the synchondrosis manubriosternalis. Nondisplaced or slightly displaced fractures (75.5%) occurred more frequently compared with moderately and severely displaced fractures (24.5%). In 29.5% of the patients, concomitant thoracic injuries were diagnosed. Spinal fractures were evaluated in 13%. In displaced fractures of the corpus, thoracic and cardiac injuries were observed frequently. In fractures or disruptions of the synchondrosis manubriosternalis, concurrence of spinal fractures clearly increased., Conclusion: The observation of fracture morphology and topography, with reference to displacement, gives important information about the existence of serious concomitant injuries and can determine further diagnostic and therapeutic options in sternal fractures.

Background: The purpose of this study was to assess the effectiveness of external fixation and percutaneous pinning in maintaining distal radius fracture reduction over a 6-month period and to identify factors that might predict loss of fracture reduction., Methods: Seventy cases had complete radiographic evaluation before surgery; at surgery; and at 6-week, 3-month, and 6-month follow-up. Radiographic parameters measured included volar tilt, dorsal displacement, radial inclination, radial height, radial shift, and ulnar variance., Results: Dorsal tilt averaged 17.5 degrees from neutral before surgery; this value was corrected to 0.9 degree at surgery, but then progressed to 4.2 degrees by the 6-month follow-up. At 6-month follow-up, 49% of cases had lost more than 5 degrees of initially reduced volar tilt. However, none of these patients went from an acceptable initial reduction to an unacceptable reduction at 6 months. Initial deformity, patient age, use of bone graft, and duration of external fixation were not predictors of loss of reduction., Conclusion: Loss of reduction of volar tilt was seen for a period of up to 6 months after fixation, despite the use of pinning to hold the reduction. No specific predictor of loss of reduction was noted, although there was a trend toward loss of reduction in younger patients.

Background: In unstable pelvic ring fractures free abdominal fluid on ultrasound (US) may be caused by retroperitoneal hematoma that passes into the abdominal cavity or by an additional intraabdominal lesion. In this study a clinical pathway for the therapy of potentially combined lesions was analyzed., Patients and Methods: All patients treated in the ED for severe trauma underwent basic sonographical and radiologic diagnostics within 15 minutes. of admission. Data were prospectively documented. According to the treatment protocol unstable pelvic ring fractures with initial free fluid on US received laparotomy. Patients with stable vital conditions had abdominal CT-Scan before surgery., Results: 1472 consecutive severely injured patients (ISS 20, age: 39 years) were included. Eighty subjects had sustained type B (47) or C (33) pelvic ring fracture. Early free abdominal fluid on US was absent in 49 cases. Three patients in this group required celiotomy later on, during ICU treatment. In 31 patients free fluid was present. All of them had laparotomy. Only one patient showed retroperitoneal hematoma alone, while all others had one or more significant lesions (rupture) that required surgical repair. Simultaneously with laparotomy pelvic stabilization was performed by external (19) or internal (6) fixation. In all cases with massive pelvic hemorrhage and free fluid in US bleeding was controlled by internal tamponade and external fixation., Conclusion: The finding of intraperitoneal fluid on US in the emergency department strongly correlates with significant intraabdominal lesions requiring surgical intervention. Early laparotomy appears indicated in these cases. Shock control in pelvic bleeding can be sufficiently achieved by internal tamponade and external fixation.

Background: This study sought to define the role of transiliac sacral rods used in combination with an external fixator for the management of unstable pelvic fractures., Methods: This retrospective study evaluated cases in which the surgical strategy was open reduction and internal fixation of posterior lesions with two transiliac sacral rods and closed reduction and external fixation of anterior lesions with an AO external fixator. The data for 65 cases were analyzed. Comprehensive Classification (AO) identified 42 C1 cases, 21 C2, cases and 2 C3 cases. Fractures with iliac bone involvement that impeded the application of an external fixator or transiliac sacral rods were excluded. The follow-up period was 85 months (range, 24-140 months)., Results: All the fractures/dislocations healed well. The complications involved 17 cases (26.2%) of persistent posterior pain, 16 cases (24.6%) of irreversible neurologic deficit, 2 cases (3.1%) of posterior wound infection, 3 cases (4.6%) of pin tract infection, and 4 cases (6.2%) of irreversible urologic deficit. The functional results showed that the surgical results were satisfactory in 42 cases (64.6%) and unsatisfactory in 23 cases (35.4%)., Conclusions: For type C pelvic fractures without significant iliac bone involvement, surgical management with posterior transiliac fixation using sacral rods and anterior external fixation yields good radiologic results. The functional results correlated primarily with avoidance of complications and not necessarily with the radiologic results.

Background: Absorbable prostheses are currently used in a variety of bone reconstructions and fixations., Methods: This is a case series of rib fracture fixation using absorbable plates and screws consisting of 70:30 poly(L-lactide-co-D,L-lactide) from April 2001 through November 2002., Results: Ten patients underwent rib fracture fixation with absorbable plates and screws. Indications included flail chest with failure to wean (five patients), acute pain with instability (four patients), and chest wall defect (one patient). All patients with flail chest weaned from mechanical ventilation successfully. All patients with pain and instability reported rapid subjective improvement or resolution. The patient with a chest wall defect repair returned to full athletic activity without limitations at 6 months. Thoracoscopic assistance was used in three cases and muscle-sparing incisions were used in eight cases. Two patients with screw fixation only developed loss of rib fracture reduction. One patient developed a wound infection requiring drainage. The period of follow-up ranged from 3 to 18 months., Conclusion: Absorbable plates produce good clinical results and are an option for rib fracture repair. Two-point fixation (screw fixation plus suture cerclage) is required. Further refinements in technique should focus on minimally invasive methods.

Background: The vast majority of metacarpal bone fractures are stable and are treated conservatively; however, when surgical intervention is to be preferred, many different operative procedures have been described. The purpose of this prospective study was to assess the anatomic and functional outcome of percutaneous transverse fixation with Kirschner wires (K-wires) of closed metacarpal neck, shaft. and intra-articular fractures of the base of the fifth metacarpal., Methods: Twenty-four consecutive patients with 25 closed metacarpal fractures were treated with this technique between 1999 and 2001. Under fluoroscopy, closed reduction and osteosynthesis with three K-wires, one proximally and two distally, was performed on the fracture site. All patients were reviewed clinically and radiologically after 3 weeks, 6 weeks, and 3 months., Results: The postoperative dorsal angulation ranged from 0 to 3 degrees. No measurable metacarpal shortening was observed. Callus formation was obvious in all fractures at 6 weeks. No complications were recorded, and all patients were cosmetically and functionally satisfied., Conclusion: Treatment of closed metacarpal neck, shaft, and intra-articular fractures of the base of the fifth metacarpal with percutaneous transverse pinning, using two K-wires distally and one proximally, has shown excellent functional and anatomic outcome.

Background: Use of a sliding hip screw (SHS) alone for some unstable intertrochanteric femur fractures can allow excessive medial shaft displacement during impaction. This study evaluated the effect of an attachable lateral support plate on these fractures after loading., Methods: Unstable, three-part intertrochanteric fractures were created in 10 matched pairs of embalmed femurs that were instrumented with 135-degree SHSs with or without an attachable lateral support plate. Under physiologic loading, inferior and lateral head displacements and lag screw sliding distances were measured., Results: After 10,000 cycles at 750 N, all measurements for femurs with the lateral support plate were significantly less than for the femurs with the SHS alone: mean lateral difference was 1.7 mm (34%) (p < 0.05), mean inferior difference was 3.0 mm (38%) (p < 0.05), and mean lag screw sliding difference was 4.5 mm (58%) (p < 0.05)., Conclusion: The addition of an attachable lateral support plate to an SHS significantly decreased displacement of the femoral head after cyclic loading.

Background: Multifocal fractures of the femur are uncommon injuries and present unique management challenges. Combined ipsilateral fractures of the femoral shaft and femoral neck or the femoral shaft and distal femur have been described. The combination of noncontiguous ipsilateral femoral neck, femoral shaft, and distal femoral articular injuries, however, has not been described. The purposes of this report are to document the incidence and characteristics of this injury and to present a treatment rationale., Methods: This was a retrospective study conducted at a Level I trauma center., Results: Over a 5-year period, 1639 adult patients with femur fractures were definitively managed at the authors' institution. Five male and two female patients (average age, 43.3 years) sustained ipsilateral, noncontiguous fractures of the femoral neck, femoral shaft, and distal femoral articular surface (0.43%). All femoral neck fractures were vertically oriented. All distal femoral injuries were unicondylar. A variety of fixation methods were used, dependent on individual fracture characteristics. The femoral neck fractures were prioritized in all cases. Stabilization of the distal femoral articular surface was then performed before diaphyseal fixation in patients with sagittally oriented condylar fractures. Patients were followed for an average of 19.3 months. All fractures healed without the need for secondary procedures., Conclusion: This injury constellation is rare. Open reduction and internal fixation of the displaced femoral neck fracture should be the primary focus of orthopedic management, followed by stable reduction and fixation of displaced distal femoral articular injuries. The diaphyseal fracture should be treated with a technique that does not jeopardize either the proximal or the distal fractures. Patients who are critically ill can be managed in a similar sequence over the course of several days, depending on their overall condition.