Faculty Bibliography

If operative treatment of a proximal diaphyseal tibial and fibular fracture is required, in most cases, it involves reduction and stabilization of only the tibial fracture. In this case report, after stabilization of the tibial fracture with an intramedullary nail, the patient continued to demonstrate significant varus knee laxity, despite an intact proximal tibiofibular joint and undisplaced fibular head. The stability of the knee was achieved only with internal fixation of the segmental fibular fracture. This case shows the importance of assessing knee laxity in all cases of proximal tibial and fibular fractures

High-energy proximal tibia fractures are complicated by soft tissue compromise and this may result in sub-optimal outcomes. There is a high association of open injuries, compartment syndromes, and vascular injuries with these bony disruptions. Surgical treatment of these injuries has been associated with significant complications such as infection, knee stiffness, malunion, loss of fixation, soft tissue failure, and amputations. The loss of fixation is an issue especially in the elderly, with failure associated with age more than sixty years, premature weight bearing, preoperative displacement, fracture fragmentation, and severe osteoporosis. The use of two-stage reconstruction for the treatment of distal tibia fractures has been successful in decreasing the complication rates, including wound compromise. The two stages involve: 1. stabilization of the injured limb with a bridging external fixator to allow the soft tissues to improve and recover and 2. definitive fixation for reconstruction of the articular surface and meta-diaphyseal fractures. The use of such a protocol has been proposed for high-energy proximal tibia fractures to decrease the high rate of soft tissue compromise associated with traditional open methods of treatment. The choice of definitive fixation may include plates, nails, or non-bridging external fixation

Rupture of the quadriceps tendon is an uncommon yet serious injury requiring prompt diagnosis and early surgical management. It is more common in older (>40 years) individuals and sometimes is associated with underlying medical conditions. In particular, bilateral spontaneous rupture may be associated with gout, diabetes, or use of steroids. Clinical findings typically include the triad of acute pain, impaired knee extension, and a suprapatellar gap. Imaging studies are useful in confirming the diagnosis. Although incomplete tears may be managed nonsurgically, complete ruptures are best treated with early surgical repair

OBJECTIVE: To determine the relationship of multiple variables, including the Injury Severity Score (ISS), closed head injury (CHI), and timing and type of surgery to formation of motion-limiting heterotopic ossification (HO) following knee dislocation. DESIGN: Longitudinal observational study. SETTING: University level 1 trauma center. PATIENTS/PARTICIPANTS: Thirty-five consecutive patients with 36 knee dislocations (OTA fracture and dislocation classification 40-D) admitted over a 26-month period. MAIN OUTCOME MEASUREMENTS: Admission ISS, Glasgow Coma scale (GCS) scores, CHI, timing (> or < 3 weeks from injury) and type (open or arthroscopic) of surgery, number of cruciate ligaments reconstructed, medial surgical procedure, and eventual presence or absence of motion-limiting HO. RESULTS: A classification system for HO was developed ranging from none (type 0) to ankylosing (type IV) HO. Twenty-nine patients with type 0-III HO recovered an average range of motion of 126 degrees at an average of 14 months (group A). Six patients formed ankylosing type IV HO (group B). The ISS in group A ranged from 9 to 26. ISS in group B ranged from 26 to 50 (P < 0.001). Regarding the formation of type IV HO, the sensitivity of an ISS >/=26 was 100%, the specificity was 97%, and the positive predictive value was 86%. Patients in group B had a greater incidence of documented CHI (P < 0.025). Timing and type of surgery, number of ligaments reconstructed, and whether or not the patient had a medial surgical procedure had no statistical influence on degree of HO formation. CONCLUSIONS: An ISS of 26 seems to be a discrete boundary above which patients with knee dislocation are at extremely high risk for type IV HO formation if undergoing surgical reconstruction and below which patients are likely spared this complication. The presence of a CHI is a significant factor in type IV HO formation, although harder to quantify. None of the remaining independent variables studied were significantly related to ankylosing type IV HO formation

Foot compartment syndrome is a serious potential complication of foot crush injury, fractures, surgery, and vascular injury. The purpose of this article is to summarize and review the existing literature on this entity. Long-term sequelae of foot compartment syndrome (FCS) include contractures, deformity, weakness, paralysis, and sensory neuropathy. These complications are poorly tolerated, and often necessitate multiple procedures for rehabilitation. Therefore, the threshold for considering compartment syndrome and performing fasciotomy must be low to minimize such outcomes. The existence of nine foot compartments and frequent presence of complicating injuries necessitate multi-stick needle catheterization for direct measurement of compartment pressures. Fasciotomy is indicated when compartment pressure exceeds 30 mmHg, or if compartment pressure is greater than 10-30 mmHg below diastolic pressure. The approaches for compartment decompression generally include two dorsal incisions for access to forefoot compartments, and one medial incision for decompression of the calcaneal, medial, superficial, and lateral compartments