Faculty Bibliography

Management of polytrauma patients has changed considerably in recent years. This is in keeping with the developments that have occurred in the fields of fracture fixation techniques and intensive care. Prior to the 1970s, patients with multiple injuries were treated non-operatively, as it was believed that they were too ill to withstand surgery. Around this time, literature appeared to suggest that these patients had high rates of complications as a result of prolonged recumbency. Fracture fixation techniques were also developing rapidly, and these events led to the advent of early fracture stabilisation of multiply injured patients, known as early total care. In the following decade, the surgical world came to recognise that early stabilisation of skeletal injuries produced poor results in certain patients. The concept of 'damage control' surgery was introduced for multiply injured patients. The current era may give way to new methods as our understanding of the pathophysiology of polytrauma improves

High-energy proximal tibial fractures are complex injuries with significant associated soft-tissue damage. There is a high percentage of open injuries, compartment syndrome, and vascular injuries in patients with these fractures. These patients usually have significant articular depression, excessive comminution, condylar displacement, and metadiaphyseal extension of the fracture. Management of these complex injuries requires treatment of the soft tissues and bony components. Surgical treatment of these injuries traditionally has been associated with substantial complications such as infection, knee stiffness, malunion, loss of fixation, soft-tissue failure, and amputations. Staged treatment, with initial application of a spanning external fixator followed by definitive fixation, has been used in recent years to decrease the risk and rate of complications. Definitive fixation may be performed using traditional open approaches or percutaneously or an external fixator may be used. Development of a protocol for treating these injuries must be done to allow optimal fracture and patient outcomes

We retrospectively reviewed the clinical and functional outcomes after operative fixation of ipsilateral fractures of the proximal ulna, radial head or neck, and radial head dislocation (Monteggia variant). Twenty of 25 patients who sustained this injury returned for followup at a mean of 2.3 years and were evaluated by an independent examiner. Radiographically, 17 of 20 fractures united after the index surgery. The three patients who had nonunions develop had Bado Type 2 fracture patterns. The fractures of two patients united after revision internal fixation, and bone grafting. Seven patients had heterotopic ossification develop and 14 of 20 patients had arthritic changes develop. The mean Broberg and Morrey score was 79.1 (range, 32.5-100) and the mean disability of the arm, shoulder and hand score was 64.1 (worse outcome than the general population). Eight of 20 patients required revision surgery (three for recurrent instability, three for nonunion of the ulna, one for radial head excision and hardware removal, and one for hardware removal alone). Nine of 20 patients had fair or poor outcomes according to the Broberg and Morrey scale. Physicians should counsel patients that functional impairment is common after these complex high-energy injuries. LEVEL OF EVIDENCE: Prognostic study, Level IV (case series). See the Guideline for Authors for a complete description of levels of evidence

OBJECTIVES: This study evaluated the use of a staged protocol involving temporary spanning external fixation and delayed formal definitive fixation in the management of high-energy proximal tibia fractures (OTA types 41) with regard to soft-tissue management, development of complications, and functional outcomes. SETTING: Two level-one trauma centers and a tertiary care orthopaedic center. PATIENTS: Fifty-three patients with 57 high-energy tibial plateau fractures. METHODS: The authors instituted a protocol of immediate placement of knee spanning external fixation with management of soft-tissue injuries for all high-energy proximal tibia fractures. Between August 1999 and May 2002, 62 consecutive patients with 67 high-energy proximal tibia fractures (OTA types 41A, B, C) underwent temporary knee spanning external fixation on the day of admission. Nine patients with 10 fractures who transferred care after initial stabilization or sustained an extraarticular fracture were excluded. The remaining 53 patients with 57 fractures underwent repair of articular fractures and meta-diaphyseal fracture repair with plates and screw constructs or conversion to a ring fixator. These patients had a mean age of 47 years (standard deviation (SD), 14). Of these 53 patients, 42 (79%) were men and 11 (21%) were women. Characteristics of the 57 fractures were: 42 Schatzker VI (74%), 12 Schatzker V (21%), 2 Schatzker IV (4%), and 1 Schatzker II (2%). There were 41 closed fractures and 16 open fractures. (One patient had bilateral fractures with 1 extremity open and 1 closed). Orthopaedic evaluation at latest follow-up included a clinical and radiographic examination and functional outcome measurement with the Western Ontario McMaster functional knee score (WOMAC). Eight patients with 8 fractures were lost to follow-up. This left 45 patients with 49 fractures with a mean follow-up of 15.7 (SD, 5.7; range, 8-40) months. RESULTS: Complications included 3 (5%) deep wound infections, 2 (4%) nonunions, and 2 patients (4%) with significant knee stiffness (<90 degrees). Nine patients (16%) underwent additional surgery after definitive skeletal stabilization related to their injury. Range of knee motion at final follow-up was 1 degrees (SD, 4) to 106 degrees (SD, 15). The mean WOMAC was 91 (SD, 55). Poor results did not correlate with demographic or injury characteristics. DISCUSSION: We had a relatively low rate of wound infection in these complex injuries (5% overall). There was only 1 wound problem in our subset of patients with closed fractures and 2 infections in those with open fractures. One downside of this technique may be residual knee stiffness. The benefits of temporizing spanning external fixation include osseous stabilization, access to soft tissues, and prevention of further articular damage. Our relatively low rates of complications in patients who sustain high-energy proximal tibia fractures and the access this technique affords in open fractures and those with compartment syndrome lead us to recommend this technique in all high-energy intra-articular and extra-articular fractures of the proximal tibia. CLINICAL RELEVANCE: This study supports the practice of delayed internal fixation until the soft-tissue envelope allows for definitive fixation

OBJECTIVES: To examine the effects of locked distal screws in retrograde nails used in unstable osteopenic distal femur fractures. DESIGN: Biomechanical testing of paired human cadaveric femurs. INTERVENTION: Seven matched pairs of embalmed, moderately osteopenic cadaver femurs were instrumented with 12-mm intramedullary nails in a statically locked, retrograde fashion. One femur of each pair had locked distal screws and the other femur had unlocked distal screws. A 2.5-cm gap of bone was cut nine centimeters from the distal condyles to simulate an unstable fracture. The locked distal screw nails were compared to unlocked distal screw nails for collapse of the fracture gap, medial-lateral and anterior-posterior translation of the nail within the fracture site, and fracture angulation. The femurs were axially loaded, cycled, and then loaded to failure. MAIN OUTCOME MEASURES: Motion at the fracture site with axial cyclic loading and site of failure when loaded to failure. RESULTS: After cycling, both locked distal screw and unlocked distal screw nails demonstrated several millimeters medial and anterior translation within the fracture site and approximately 1 mm collapse of the fracture gap. Although no statistically significant differences were found, the locked distal screw nails had less anterior and medial translation, angulation, and collapse of the fracture gap after cycling. Loads to failure were similar for both locked distal screw and unlocked distal screw nails. It was noted that proximal femur failure occurred at the level of the proximal screw hole in the nail at the subtrochanteric level in 7 (4 locked distal screws and 3 unlocked distal screw groups) of the 14 samples. Four other samples failed through the intertrochanteric region (2 locked distal screw and 2 unlocked distal screw groups) and the remainder within the distal fragment by fracture of the femur along the medial cortex. CONCLUSIONS: Although most differences in fixation stability were not significant, the locked distal screw nails exhibited less fracture collapse and anterior and medial translation of the nail at the fracture site than the unlocked distal screw nails. The degree of varus angulation after cyclic loading was also less for the locked distal screw nails. The length of the nail chosen should avoid having proximal locking screws distal to the lesser trochanter, thus averting proximal femur stress risers and fractures

Osteochondral lesions of the talus occur infrequently and usually represent late sequelae of ankle trauma. Because of the functional significance of the talus and its limited capacity for repair, correct early diagnosis is important. Osteochondral fractures should be suspected in patients with chronic ankle pain, especially those with a prior ankle injury. Historically, plain radiographs have been used to stage lesions; more recently, magnetic resonance imaging and arthroscopy have been used. Non-surgical management remains the mainstay of treatment of acute, nondisplaced osteochondral lesions. Surgical management is reserved for unstable fragments or failure of nonsurgical treatment. Recent advances in osteochondral grafting have allowed reconstruction of the talar dome, leading to more predictable relief of pain and improvement of function

Hip fractures have been among the most studied injury patterns in adults. The number of hip fractures is increasing exponentially, and their treatment costs place great economic strain on society. Recently developed hip fracture treatments, emphasizing cost containment, deformity prevention, and evidence-based medicine, are attempts to optimize patient outcomes. In this article, we outline some of these developments with respect to femoral neck and intertrochanteric fractures

BACKGROUND: The purpose of this study was to confirm the prevalence of medial ankle widening among patients with an isolated fibular fracture and to determine the functional outcome of nonoperative treatment despite a diagnosis of a supination-external rotation stage-IV injury based on stress radiography. METHODS: One hundred and one patients with evidence of an isolated fibular fracture and an intact mortise seen on a standard ankle trauma radiograph series were evaluated with stress radiographs. Clinical signs were recorded at the time of presentation. A positive stress test was defined as > or =4 mm of widening of the medial clear space. Patients with a negative stress test were treated nonoperatively, those with a positive stress test and clinical signs of medial injury were treated surgically, and those with a positive stress test and no signs of medial injury were treated according to the preference of the surgeon and patient. The patients were followed prospectively with radiographs and ankle outcome scores. RESULTS: Sixty-six (65%) of the 101 patients had a positive stress radiograph. Thirty-six of them had signs of medial injury, and thirty had no medial injury. With regard to predicting a positive stress radiograph, medial tenderness had a sensitivity of 56% and a specificity of 80%, swelling had a sensitivity of 55% and a specificity of 71%, and ecchymosis had a sensitivity of 26% and a specificity of 91%. Of the subset of patients without signs of medial injury, twenty were treated nonoperatively (group I) and ten were treated operatively (group II). Two of the twenty patients in group I had evidence of persistent widening of the medial clear space at the time of the latest follow-up (mean, 7.4 months); only one of those patients was symptomatic. The average American Orthopaedic Foot and Ankle Society (AOFAS) score was 94 points in group I and 93 points in group II. CONCLUSIONS: We found a high rate of positive stress radiographs for patients who presented with an isolated fibular fracture and an intact ankle mortise on the initial radiographs. Medial tenderness, swelling, and ecchymosis were not sensitive with regard to predicting widening of the medial clear space on stress radiographs. All of the patients with a positive stress radiograph and no clinical symptoms who were treated without surgery had a good or excellent clinical result