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Background: Olecranon osteotomies are frequently performed to gain access to the distal humeral articular surface. Repair of the osteotomy or fixation of a simple 2-part olecranon fracture with traditional tension band construct is often plagued by complication. Proximal migration and irritation attributed to hardware are common complications of the standard construct of an intramedullary screw with tension band and are causes for reoperation., Purpose: To compare the biomechanical performance, time of implant, and prominence of an intramedullary screw and tension band construct with that of a newer low-profile continuous loop tension band (Olecranon Sled) construct in an olecranon osteotomy model., Study Design: Controlled laboratory study., Methods: Chevron osteotomies were created in 6 matched pairs of fresh-frozen human elbows (mean age, 66 ± 16 years). Each matched pair was then randomly divided into 1 of 2 groups: fixation with a screw and tension band construct or the Olecranon Sled. Bone mineral density, implant prominence, and time for implantation were recorded. Following olecranon fixation, each specimen underwent cyclic loading of 0 to 10 N for 100 cycles (to simulate unresisted active range of motion) and then 0 to 500 N for 500 cycles (to simulate pushing up from a chair) to measure for any displacement at the osteotomy site. The constructs were then loaded to failure and compared., Results: No differences were found in bone mineral density between the 2 groups ( P = .290). When measured from the tip of the olecranon, the continuous loop tension band had a medial prominence of only 3.57 ± 0.4 mm, as opposed to the intramedullary screw fixation of 7.288 ± 0.762 mm ( P = .027). Total time of implantation, including osteotomy preparation, was a mean 155 seconds shorter with the Olecranon Sled versus the traditional tension band ( P < .05). Because of the fracture of 1 specimen during cyclic loading, it and its matched counterpart were excluded, and only 5 matched pairs were analyzed for displacement and load to failure. There were no significant differences between groups in load to failure or displacement during cyclic loading ( P > .05)., Conclusion: The Olecranon Sled device was found to have no difference in biomechanical strength from that of the standard intramedullary screw with tension band construct. The Olecranon Sled was also found to be significantly less prominent while being faster to implant than the intramedullary screw., Clinical Relevance: Evaluating an alternative option to the standard tension band construct is important for patients with olecranon fractures or osteotomies, as standard techniques have been fraught with hardware issues and need for revision surgery., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study received funding from the Greater Hartford Orthopedic Research and Education Fund and from Arthrex. The implants were provided by TriMed and Synthes USA. No funding providers had any influence on the study design, data collection, or final manuscript. A.D.M. is a consultant for Arthrex, Arthrosurface, and Orthofix and receives research support from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Objectives: Open fractures are one of the injuries with the highest rate of infection that orthopaedic trauma surgeons treat. The main purpose of this survey was to determine current practice and practice variation among Orthopaedic Trauma Association (OTA) members and make treatment recommendations based on previously published resources., Design: Survey., Setting: Web-based survey., Participants: Three hundred seventy-nine orthopaedic trauma surgeons., Methods: A 15-item questionnaire-based study titled "OTA Open Fracture Survey" was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze numerous aspects of open fracture management, focusing on parameters of initial and definitive treatment., Results: Eighty-six percent of participants responded that a period of time of less than 1 hour is the optimal time to antibiotic administration after identification of open fracture. Despite concerns with nephrotoxicity, 24.0%-76.3% of respondents reported the use of aminoglycosides in management of open fractures. A little over half of survey respondents continue antibiotics until next debridement in wounds that were not definitively closed after initial debridement and stabilization., Conclusions: Rapid administration of antibiotics in open fracture management is important. Aminoglycoside use is still prevalent despite evidence questioning efficacy and toxicity concerns. Time to debridement of open fractures is controversial among OTA members. Antibiotic administration is commonly continued >48 hours despite concerns raised by Surgical Infection Society and The Eastern Association of the Surgery of Trauma. Regarding study logistics, survey participation reminders should be used when conducting this type of study as it can increase data accrual by 50%., Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Motorcycle-related head injuries and fatalities are a serious public health concern that can be reduced with helmet use. Caring for crash victims places additional economic stress on the healthcare system. The current Connecticut motorcycle helmet law does not require all motorcyclists to wear helmets. Universal motorcycle helmet laws increase helmet use. Efforts to increase helmet use through education and legislation should be considered for review, given the number of deaths and injuries that could be prevented.

Background: The concept of mentoring is believed to be influential in an effective medical and surgical educational environment. Several authors have discussed the issue of mentorship and its challenges, yet no one has studied the prevalence of mentoring among orthopaedic residency programs and its perceived value from the orthopaedic residents' perspective., Methods: Between January 1, 2008, and February 1, 2008, a survey created by the American Academy of Orthopaedic Surgeons was distributed by mail and e-mail to 3655 orthopaedic residents to obtain their opinion of the value of and their experience with mentorship., Results: Five hundred and six (14%) of the surveyed residents responded. Nearly half of the responding residents either had a mentor or were involved in a mentoring program. Nearly all ranked the value of mentorship as very high and anticipated substantial help from their mentor in their career, research, and education. Only 44% were satisfied with their mentoring environment, and only 17% were highly satisfied. The residents were most satisfied with mentoring when there was a formal program in place. Ninety-six percent of the respondents thought that mentors were either critical or beneficial to their training. Residents who had selected their own mentor were more satisfied with their mentor than were those who had their mentor assigned., Conclusions: Residents with mentors, residents in mentoring programs, and residents who selected their own mentors had higher satisfaction with their mentoring environment than did those with no formal mentoring program. Residency programs should consider establishing formal mentorship programs and encourage residents to select their own mentors.

Purpose: Tension band constructs are commonly used for olecranon fracture fixation. The purpose of this study was to determine if a tension band constructed of FiberWire (Arthrex, Naples, FL), a high-strength polyester and polyethylene suture, will provide fixation that is equivalent to an 18-gauge metal wire tension band., Methods: The following 4 fixation methods were biomechanically tested in cadaveric elbows with a simulated transverse olecranon fracture: (1) Kirschner wires (K-wires) with an 18-gauge metal wire tension band, (2) K-wires with a FiberWire tension band, (3) intramedullary screw with an 18-gauge metal wire tension band, and (4) intramedullary screw with a FiberWire tension band. Each elbow underwent all 4 repair methods. The K-wire repairs were performed first followed by the intramedullary screw repairs. The order of the tension band (FiberWire or metal wire) was randomly assigned. Specimens were tested under cyclic loading conditions that simulated stresses generated by (1) active range of motion and (2) pushing up from a chair. Fracture displacement was recorded by using transducers placed at the articular surface of the fracture and on the posterior surface of the olecranon., Results: There were no significant differences in fracture displacement associated with the use of a high-strength suture or metal wire tension band under conditions simulating active range of motion or a more vigorous physiologic stress. Also, there were no significant differences associated with the use of an intramedullary screw versus K-wire fixation under either condition., Conclusions: The biomechanical characteristics of high-strength suture tension bands are equivalent to 18-gauge metal wire tension bands when used with either an intramedullary screw or K-wires. The fatigue patterns of high-strength suture tension bands and metal wire tension bands are similar. There is not a significant difference between the biomechanical strength of intramedullary screw fixation constructs and K-wire constructs., Clinical Relevance: FiberWire tension bands may be used in place of metal wire tension bands without sacrificing fixation strength.

Background: The pathology of chronic osteomyelitis suggests that thorough debridement of bone and soft tissue, with closure of dead space, supported by appropriate antibiotics would be the optimal therapeutic strategy., Methods: In 1993, we formed a multidisciplinary Bone Infection Team (orthopaedic surgeon, infectious diseases specialist, plastic surgeon, and nurse practitioner) to apply those principles to the treatment of chronic osteomyelitis. We present the outcomes of such therapy in 82 patients treated by the Team in the first seven years. All patients underwent surgical debridement with other procedures including bone distraction, muscle flap implantation and bone grafts as necessary to foster restoration of bone and soft-tissue integrity. Antibiotic choice was based on sensitivity data, with a short course of intravenous antibiotics and a prolonged course of oral antibiotics being the usual therapy., Results: During the first seven years, we treated 82 patients for chronic osteomyelitis. Most patients required multiple surgical procedures (mean = 2.2), with 10 patients requiring five or more operations. Staphylococcus aureus was the single most common pathogen, although the majority (57%) of the infections were polymicrobial. Intravenous antibiotics were administered for a median of 16 days; 16 patients received intravenous antibiotics only during the immediate perioperative period. Oral antibiotics were administered for a median of 59 days. The infection was cured in all but one patient in our clinic; the remaining patient had definitive surgical repair at another clinic and is now infection free. In 77/82 patients, the limb afflicted with chronic osteomyelitis was salvaged. Because of extensive damage to bones and surrounding soft tissues, amputation was necessary in five patients. Five patients required internal fixation 12 or more months after the infection was controlled for nonunion; all such procedures were successful. No patient whose infection remained inactive for six or more months after surgical debridement has reactivated the infection during a median follow-up of 56 months (range: 23-89 months)., Conclusions: Management of chronic osteomyelitis requires thorough debridement of infected bone and soft tissues coupled with rigid stabilization with external fixators, elimination of dead space, often requiring soft-tissue flap coverage, and staged bone reconstruction. When such a surgical approach is accompanied by appropriate antibiotics based on the sensitivity of the microbes isolated from the infected site, the infected focus is eliminated and bone length and integrity are restored.

Previous spinal fusion outcomes assessment studies have been complicated by inconsistencies in evaluative criteria and consequent variations in results. As a result, a general consensus is lacking on how to achieve comprehensive outcomes assessment for spinal fusion surgeries. The purpose of this article is to report the most validated and frequently used assessment measures to facilitate comparable outcomes studies in the future. Twenty-seven spinal fusion outcomes studies published between 1990 and 2000 were retrospectively reviewed. Study characteristics such as design, evaluative measures, and assessment tools were recorded and analyzed. Based on the reviewed literature, an outcomes assessment model is proposed including the Short Form-36 Health Survey, the Oswestry Disability Questionnaire, the North American Spine Society Patient Satisfaction Index, the Prolo Economic Scale, a 0-10 analog pain scale, medication use, radiographically assessed fusion status, and a generalized complication rate.

The previous 20 years have truly opened a new era of orthopedic trauma care. Rapid advances in the development of systems for internal and external fixation have been made. Improvements in technology and surgical technique have allowed fracture reduction and fixation to be achieved with less-invasive surgical approaches. This has reduced postoperative morbidity, decreased hospitalization, and expedited the recovery of function. A new understanding of processes at the cellular and molecular levels offers the possibility, for the first time, of directly influencing the biology of fracture union and soft-tissue healing. Transitional research has introduced new therapies that are moving rapidly from the laboratory to biotech industry and the clinical arena. Given the present state of scientific acceleration, orthopedic trauma care in the new millennium will be shaped by important developments that physicians can now only imagine.

This study was performed to investigate the potential utility of ofloxacin-impregnated bioabsorbable polymers for osteomyelitis therapy. Pseudomonas aeruginosa osteomyelitis was induced in 48 New Zealand White rabbits. Four weeks after infection, the animals were randomized to one of four treatment groups: drug-free polymer, ofloxacin polymer, systemic ofloxacin, or ofloxacin polymer plus systemic ofloxacin. Twenty-eight days later, radiographs were taken of the affected area, the animals were killed, and bone was obtained for histologic evaluation, culture, and determination of ofloxacin concentrations. The percentage of sterile bone cultures was 33, 83, 75, and 91 for the groups treated with drug-free polymer, ofloxacin polymer, systemic ofloxacin, and ofloxacin polymer plus systemic ofloxacin, respectively. When compared with the drug-free polymer, both the ofloxacin polymer and the ofloxacin polymer plus systemic ofloxacin significantly improved the rate of sterilization. The mean concentrations of the drug in bone for the groups treated with ofloxacin polymer, systemic ofloxacin, and ofloxacin polymer plus systemic ofloxacin were 34.9 (range: 2-160), 1.9 (range: 0.8-3), and 26.0 microg/g (range: 9-100 microg/g), respectively. These data suggest that the DL-lactide:glycolide polymer studied is a suitable vehicle for the delivery of high local concentrations of ofloxacin and that these concentrations result in eradication of the bacterial pathogen in this rabbit model.

As advancements are made in the prevention of automobile fatalities, an increase in the incidence of pelvic and lower extremity injuries has occurred. These remain the leading causes of impairment and loss of years of productive life. Pelvic trauma has a high initial mortality rate when severe. However, with early resuscitation and transport, more survivors arrive in our trauma centers harboring these injuries. Owing to early stabilization and mobilization of the traumatized patient, a decrease in complications in these patients has been noted. Both the trauma surgeon and the orthopedic trauma surgeon should work as a team and remain in continuous communication during the treatment of these patients. Open fractures are among the most difficult problems to manage; early and aggressive decisions can prevent a lifetime of complications and physical impairment. As previously stated, to obtain good outcomes, open fractures must be treated initially at the accident scene followed by timely transport to the trauma center for definitive care. It must be remembered that the golden time to prevent major complications is 6 hours. Intra-articular fractures of the lower extremity involve a major weight bearing joint. Post-traumatic arthritis and impairment develop in joints where joint congruity is not achieved. To preserve normal function, there should be articular congruity, stable fixation, axial alignment with the rest of the extremity, and restoration of full range of motion. Immediate stabilization of long bone fractures has many advantages in the multiply injured patient, such as improved long-term function, prevention of deep venous thrombosis and decubitus ulcer, decreased need for analgesia, and reduction in the incidence of adult respiratory distress syndrome and fat emboli. Patients with femoral shaft fractures should undergo immediate stabilization of the fracture within 24 hours of injury. We have presented a series of orthopedic injuries that have high mortality and high morbidity which, if not treated expediently, yield a high degree of impairment.

A series of 36 patients with 20 subtrochanteric fractures, 12 ipsilateral neck/shaft fractures, and five intertrochanteric fractures with shaft extension underwent closed intramedullary nailing with the Russell-Taylor reconstruction (RECON) nail. The average Injury Severity Score was 16, and seven of the fractures were open. All fractures were acute injuries, and all but one were treated within 24 hours of admission. Follow-up was obtained at three, six, nine, 12, and 24 months or until the fracture healed. The range of follow-up was one to three years. Complete follow-up was obtained in 33 of 36 patients. Union was achieved in all acute fractures. Shortening occurred in two cases and chondrolysis and avascular necrosis occurred in another patient. Excellent hip and knee range of motion were obtained except in a few cases of ipsilateral limb injuries. While many complex femoral shaft fractures can be treated successfully with first generation locking nails, this study demonstrates that second generation locking nails, such as the RECON nail, offer the added strength and design features necessary for more effective treatment of complex proximal and ipsilateral femoral neck/shaft fractures.

Posterior hip dislocation associated with acute injury to the thoracic aorta is a previously unrecognized injury complex. This study reveals that 8% of patients with posterior hip dislocation have associated injury to the thoracic aorta because of abrupt deceleration injuries. This study defines the association of traumatic posterior hip dislocation and acute traumatic injury of the thoracic aorta, describes the mechanism of injury, and discusses the evaluation of a patient with a suspected acute traumatic aortic injury.

This study was undertaken to determine the specificity of indium-111 leukocyte scans for osteomyelitis when fractures are present. Midshaft tibial osteotomies were performed in 14 New Zealand white rabbits, seven of which were infected postoperatively with Staphylococcus aureus per Norden's protocol. All 14 rabbits were scanned following injection with 75 microCi of indium 111 at 72 h after osteotomy and at weekly intervals for 4 weeks. Before the rabbits were killed, the fracture sites were cultured to document the presence or absence of infection. The results of all infected osteotomy sites were positive, whereas no positive scans were found in the noninfected osteotomies. We concluded from this study that uncomplicated fracture healing does not result in a positive indium-111 leukocyte scan.

During interlocking intramedullary nailing of twenty-five femoral and five tibial fractures, the primary surgeon wore both a universal film badge on the collar of the lead apron and a thermoluminescent dosimeter ring on the dominant hand to quantify the radiation that he or she received. When distal interlocking was performed, the first ring was removed and a second ring was used so that a separate recording could be made for this portion of the procedure. At the conclusion of the study, all of the recorded doses of radiation were averaged. The average amount of radiation to the head and neck during the entire procedure was 7.0 millirems of deep exposure and 8.0 millirems of shallow exposure. The average dose of radiation to the dominant hand during insertion of the intramedullary nail and the proximal interlocking screw was 13.0 millirems, while the average amount during insertion of the distal interlocking nail was 12.0 millirems. Both of these averages are well within the government guidelines for allowable exposure to radiation during one-quarter (three months) of a year. Precautions that are to be observed during this procedure are recommended.

The addition of percutaneously inserted transfixion screws or internally deployed fins supplements the stabilization potential of the cloverleaf nail. The use of these systems increases the indications for reamed closed intramedullary nailing. Fractures with comminution or bone loss, malunions, and nonunions located outside of the isthmic region of the femur and the tibia can now be stabilized effectively with a Küntscher-type implant. These closed nailing techniques reduce blood loss, surgical stress, and complications associated with open reduction and offer the patient the advantages of early joint and muscle rehabilitation and shorter hospitalization. However, the added technical complexity associated with the locking nail introduces a new set of pitfalls, errors, and complications. This article discusses these problems and suggests means to alleviate or avoid certain difficulties.

A case is presented in which the leg segments of MAS trousers were deflated without deflating the abdominal segment, causing the trousers to act as a venous tourniquet. As a result bleeding and edema secondary to a pertrochanteric hip fracture were aggravated, causing a compartment syndrome in the thigh; fasciotomy became necessary. MAS trousers must be inflated in proper sequence, the leg segments first and then the abdominal portion. In deflation, the order is reversed. Only if this sequence is followed can MAS trousers be used safely.

Massive trauma involving the foot was treated by external fixation in 33 cases and followed for 1 to 3 years. Amputations were performed in seven (21%) because of uncontrollable deep sepsis in two and massive injury in five. The other 26 (79%) had functionally acceptable feet at follow-up, but all had some stiffness and cosmetic deformity. Complications attributed to the Hoffman external fixation were limited to three pin tract infections. We recommend Hoffmann external fixation when it is necessary to: 1) stabilize major open fracture dislocations; 2) maintain length where bone is lost or extensively comminuted; 3) prevent soft tissue contractures; 4) control joint position for delayed ankle arthrodesis; and 5) provide easy access for soft and bone tissue reconstructions.

The choice of treatment modalities for the fractured femur in the polytrauma patient is a continuing dilemma. Prevention and treatment of respiratory complications requires maximum patient mobility. Conventional traction methods restrict turning in bed and preclude moving the patient out of bed. Immediate open reduction results in additional blood loss, tissue trauma, and a higher rate of infection and nonunion. Immediate closed intramedullary nailing is an excellent method but requires special equipment and surgical expertise. To meet the mobilization requirements of good pulmonary care and avoid the problems of early open reduction, before the availability of immediate closed nailing, we adopted the use of modified Neufeld single-rope roller traction for the initial treatment of closed, Grade I open, and some Grade II open femur fractures. In 30 cases, the traction was used to maintain the fracture for 7 to 14 days preceding delayed internal fixation, while in another 22 cases of the traction was used as the definitive treatment modality in conjunction with case bracing. Sixty patients with femoral fractures were treated with this traction methods. Eight patients died, the other 52 were followed to fracture healing. There was one delayed union. There were no nonunions and no wound infections in either the internal fixation or continued traction groups. This traction system is an effective way to meet the needs of the polytrauma patient with a femur.

Modern methods of open fracture management, skeletal fixation, and soft-tissue and bone reconstruction have dramatically improved the potential for limb salvage. The absence of adequate objective parameters on which to base the decision for salvage results in delayed amputations in many cases. The present study was undertaken to review the medical and economic impact of delayed versus primary amputations following severe open fractures of the tibia. From January 1980 to August 1986, 263 patients with grade III open tibia fractures were treated at a major trauma center: 43 ultimately had amputations. This group included 38 males and five females with an average age of 31 years (range, 15-73). All patients were taken to the operating suite for consideration of limb salvage procedures including debridement, fasciotomy, revascularization, or rigid fixation. The standard subjective criteria including color, consistency, bleeding, and contractility were used to determine muscle viability at the time of debridement. If substantial muscle mass was found to be nonviable then amputation was considered. Fourteen (32.6%) of the patients had primary amputations. They averaged 22.3 days hospitalization, 1.6 surgical procedures to the involved lower extremity, and $28,964 hospital costs (range, $5,344-$81,282). The 29 patients with delayed amputations had an average of 53.4 days hospitalization, 6.9 surgical procedures, and $53,462 hospital costs (range, $14,574-$102,434). Six (20.7%) of the delayed amputation patients developed sepsis secondary to their involved lower extremity and died; no patient in the primary amputation group developed sepsis or died.(ABSTRACT TRUNCATED AT 250 WORDS)

There have been many improvements made in external fixation, and fixators are being applied with renewed enthusiasm. Inspite of advances in design and application, complications related to the treatment of open fractures are still frequent. Although external fixation has dramatically improved the treatment of open fractures and made possible the salvage of previously amputated limbs, it is a complex technique with many pitfalls. These problems fall into two broad categories: those related to the application and maintenance of the pins and frame on one hand, and those related to the management of soft tissue and bony injuries on the other.

Grade III open tibial fractures are known for frequent complications and poor clinical results, yet published series are few and cite conflicting results. To address this dilemma, the authors report a prospective study of 202 consecutive Grade III tibial fractures. All injuries were treated under protocol at the authors' university with primary external fixation and serial debridement. Equinus deformity was prevented with a new tibiometatarsal frame extension. Severe injuries crossing the ankle or knee were temporarily stabilized with external fixation across these joints. Staged reconstruction of soft tissue and then bone was undertaken for 176 of these tibias in patients who survived their multiple injuries. Reconstructive procedures included skin grafts in 57%, muscle flaps in 32%, and bone grafts in 28%. Gastrosoleus myocutaneous flaps were successful in 92% of cases versus 66% for free flaps. Late follow-up data were obtained for 171 (97%). Infection occurred in 15% and led to amputation in 7%. The infection rate was reduced to 9% in the second half of the series largely by removal of all necrotic bone prior to wound coverage. Angulation (greater than 10 degrees) in 9% and delayed union were lessened with early posterolateral grafting followed by progressive fracture loading in the fixator. A 9% incidence of pin tract drainage or loosening was reduced with predrilling and diaphyseal half pins. The time to fixator removal averaged 87 days. Ninety-three percent of the fractures united (median time, nine months) but healing times varied widely according to the amount of tissue injury and bone loss. Eighty-nine percent had satisfactory late clinical function. Results from this study, the largest series of open Grade III tibial fractures reported to date, suggest that successful staged reconstruction is now a reasonable expectation for most of these severe injuries.

Fifteen patients with unstable pelvic fractures were treated with immediate anterior external fixation followed by delayed posterior fixation, including five sacroiliac lag screws, six transiliac rods, and four iliac plates. Initial anterior external fixation aided in resuscitation of hemodynamically unstable patients and allowed early mobilization. Delayed posterior internal fixation avoided infection and hemorrhage but failed to achieve anatomic reduction of disrupted sacroiliac joints and sacral fractures. Followup examination confirmed maintenance of fixation and fracture healing but pain and persistent neurologic deficits were common findings. Lumbosacral nerve plexus injuries occurred in patients with fractures through the sacral foramina. Fixation of these fractures with sacroiliac screws and transiliac rods caused overcompression and the resulting foraminal encroachment may be a factor in the lack of neurologic recovery. In this study, delayed posterior internal fixation was not associated with perioperative morbidity and achieved better reductions than those obtained with external fixation alone. Delaying the fixation, however, increased the difficulty of obtaining anatomic reduction of certain posterior arch disruptions.

Fifty-four trauma patients with 61 femoral fractures stabilized within the first 24 hours of admission by closed antegrade Ender nailing were included in this study. This technique involves the insertion of Ender nails from a portal at the proximal end of the femur through the piriformis fossa. The curved distal ends of the nails were distributed throughout the distal femur to achieve greater purchase in the enlarged medullary canal of the distal fragment. This technique was used in one proximal, 20 midshaft, 37 distal, and three segmental fractures. There were 51 closed fractures, eight Grade I open, and two Grade II open fractures. The average age of the patient was 26 years, and the majority had polytrauma. The operative procedure was well tolerated by this group of patients. Pulmonary care was improved by avoidance of traction and enhanced capability for mobilization. Forty-two patients with 49 femoral fractures were available for complete follow-up. Forty-five fractures healed with the average time to appearance of bridging callus being 33 days, and average time to full union remodeled callus being 5.9 months. There were four nonunions, one delayed union, and eight malunions. There were nail protrusions in 22 cases (19 proximal and three distal). Fourteen patients required a second operation for reimpaction of the protruding nails or premature nail removal. These results were inferior to those obtained with the use of the retrograde Ender nailing technique or the Kuntscher nail. This technique should be used only if other techniques are unavailable or inappropriate, and only for stable, noncomminuted fractures.(ABSTRACT TRUNCATED AT 250 WORDS)

The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) was appointed by President Trunkey at the 1987 Annual Meeting. The principal charge was to devise injury severity scores for individual organs to facilitate clinical research. The resultant classification scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. A number of similar scales have been developed in the past, but none has been uniformly adopted. In fact, this concept was introduced at the A.A.S.T. in 1979 as the Abdominal Trauma Index (A.T.I.) and has proved useful in several areas of clinical research. The enclosed O.I.S.'s for spleen, liver, and kidney represent an amalgamation of previous scales applied for these organs, and a consensus of the O.I.S. Committee as well as the A.A.S.T. Board of Managers. The O.I.S. differs from the Abbreviated Injury Score (A.I.S.), which is also based on an anatomic scale but designed to reflect the impact of a specific organ injury on ultimate patient outcome. The individual A.I.S.'s are, of course, the basic elements used to calculate the Injury Severity Score (I.S.S.) as well as T.R.I.S.S. methodology. To ensure that the O.I.S. interdiffuses with the A.I.S. and I.C.D.-9 codes, these are listed alongside the respective O.I.S. Both the currently used A.I.S. 85 and proposed A.I.S. 90 are provided because of the obligatory transition period. Indeed, A.I.S. 90 contains the identical descriptive text as the current O.I.S.'s. The Abdominal Trauma Index and other similar indices using organ injury scoring can be easily modified by replacing older scores with the O.I.S.'s.(ABSTRACT TRUNCATED AT 250 WORDS)

Judging the appropriate time for amputating lower extremities with open fractures and major soft tissue damage is a major problem for physicians. Limb salvage through vascular repair and external fixation is frequently unjustified. Attempts at saving a limb that should be amputated often are followed by renal failure, sepsis, and death. Much research remains to be done in this area.

We have each experienced a significant learning phase for surgical treatment of these fractures. However, problems of articular reduction remain significant, particularly for complex fractures. It is our opinion that a certain degree of centralization of acetabulum fracture treatment--especially for the associated types--can lead to an improved standard of care overall.

Functional residual capacity (FRC) was measured in 12 postoperative patients and in one preoperative patient before and after they received intermittent positive pressure breathing (IPPB) with room air for ten minutes at a peak delivered pressure of 15 cm H2O. Ten patients had a normal or low pretreatment FRC. After cessation of IPPB, the mean FRC decreased further. Arterial oxygen tensions, measured in 11 of the 13 patients, decreased in all 11 from a pretreatment mean of 67.8 +/- 4.3 mm Hg to an immediate posttreatment mean of 57.7 +/- 4.2 mm Hg. In five patients repeated arterial blood gases were measured. At 30 minutes, their arterial oxygen tensions had returned to the pre-IPPB values. This study demonstrates that the routine use of IPPB in postoperative patients accentuates preexisting hypoxia and, therefore, must be used with caution.

Anteroposterior pelvic roentgenograms of 154 patients with pelvic ring disruptions were evaluated to assess their value in the determination of pelvic instability. Three different categories of stability were roentgenographically recognizable: (1) stable, characterized by impacted vertical fracture of the sacrum, nondisplaced fracture of the posterior sacroiliac complex, and/or subtle fractures of the upper sacrum evidenced by asymmetry of the sacral arcuate lines; (2) unstable, characterized by hemipelvic cephalad displacement exceeding 0.5 cm, sacroiliac joint diastasis exceeding 1 cm and/or sacral or iliac diastatic fracture exceeding 0.5 cm; and (3) indeterminate (that is, suspicious but not diagnostic of pelvic instability), characterized by cephalad hemipelvic displacement of less than 0.5 cm, sacroiliac joint diastasis less than 1 cm, and/or diastatic fracture of the sacrum or ilium of less than 0.5 cm. Correlation of the standard roentgenographic, computed tomographic, and clinical orthopedic examinations revealed that pelvic stability was accurately evaluated on the standard pelvic roentgenograms in 88% of cases. Disruptions were stable in 70%, unstable in 18%, and suspect in 12% of patients, for whom adjunct roentgenographic and clinical examinations were required. Determination of pelvic stability in the manner described allows immediate identification of patients with a stable or unstable pelvic injury, as well as identification of those with indeterminate stability requiring further clinical or roentgenologic evaluation. Immediate recognition of pelvic instability on standard pelvic roentgenograms obviates the need for additional diagnostic studies that unnecessarily delay the institution of emergency therapeutic measures designed to control associated hemorrhage.

Cardiac output and pulmonary wedge pressure (PWP) were used to evaluate the end point of fluid resuscitation in 20 patients suffering from multiple trauma and shock. Eleven patients received crystalloid resuscitation and nine patients received colloid resuscitation. Fifteen of 20 patients had an adequate cardiac output at the termination of resuscitation, but but only six of these patients had a PWP above 10 mm Hg. There was no significant correlation between left ventricular stroke work index and PWP in these patients, either at the completion of resuscitation or during the following three days. Five patients did not achieve adequate cardiac output and four of these patients died, suggesting that cardiac output was the most important criterion for adequate resuscitation. If the goal of fluid resuscitation is to achieve an adequate cardiac output, then PWP was not a reliable guide. Furthermore, using both cardiac output and PWP as a guide to fluid resuscitation of our patients, we found that the type of fluid (crystalloid or colloid) for resuscitation did not influence the course of respiratory distress in these patients up to three days following resuscitation.