Rigid internal fixation for fractures involving tooth-bearing maxillary segments

Fracture dislocations of the middle third of the face usually involve a complex combination of the three types of fractures initially described by LeFort. Treatment of these injuries requires a six- to eight-week period of intermaxillary fixation, unless rigid internal fixation devices (plates and screws) are used to stabilize the fractures. However, rigid fixation carries the risk of producing a malunion and serious malocclusion if not performed correctly. A review of 22 patients with complex LeFort fractures treated with rigid fixation revealed that the only absolute contraindication to its use is difficulty in interdigitating the maxillary and mandibular teeth in a passive fashion at the time of fracture reduction. Rigid internal fixation should therefore be considered as an alternative treatment for most fractures of the middle third of the face.

Fractures of the sternum

The records of 71 patients treated for sternal fracture were reviewed: 52 patients sustained isolated sternal fracture, 19 patients had a sternal fracture in combination with multiple other injuries, with in 12 patients only rib fractures. Forty-one patients were involved in a car accident, 29 of them used safety belts. Three patients (3/71, 4%) died, two multitrauma patients, in whom artificial ventilation was necessary, died of multiple organ failure. One patient with a sternal fracture and bilateral multiple rib fractures died of cardiac contusion and myocardial infarction. Three patients (3/71, 4%) showed signs of myocardial contusion. The morbidity in the patients with an isolated sternal fracture was very low. The prognosis of an isolated sternal fracture is good. Cardiac contusion was an uncommon complication of sternal fracture. Clinical observation for only a short period is advised.

Fracture of the fabella

A very rare case of traumatic avulsion fracture of the fabella in a middle-age lady, presented as intermittent posterolateral localized knee pain accentuated by compression against the lateral femoral condyle and by active and passive knee extension, is illustrated. The accumulated chronic microtrauma of the osteoarthritic fabello femoral joint in this lady especially during the whip-kick of daily breaststroke swimming for over 30 yr, may precipitate a fabella stress fracture. Radiographs reveal bilateral fabellae with a left bipartite fabella as a stress fracture traversing it without displacement; this later became a completely displaced bipartite avulsion fracture after accidental knee hyperextension. Conservative treatment consisted of anti-inflammatory/analgesic cream, cryotherapy, TENS, strapping and avoiding knee hyperextension.

Office evaluation and management of acute orthopedic trauma

Virtually any injury that can be treated as an outpatient can be treated in a properly equipped and staffed orthopaedist's office, provided that it is accurately identified and evaluated initially. Anesthetic blocks, closed manipulations, some suturing, and immobilizations can all be done in the acute setting. Children and elderly patients are particularly suited to office treatment. Close follow-up is essential, and early rehabilitation can begin in the office setting.

Ankle injuries and the family physician

In transmitting the body's weight, the ankle is subject to frequent static and dynamic injury due to concentrated stresses during standing and movement. The frequency of athletic ankle injuries ranges from 10 to 90 percent, with the highest rate occurring in basketball players. There is prolonged disability and recurrent instability for months to years for 25 to 40 per cent of these patients. Because most of this trauma is handled by primary care physicians, this review presents the mechanism of injury, relevant anatomy, physical examination, and appropriate therapeutic intervention in the acute and rehabilitative phases.

Extrication, immobilization and radiologic investigation of patients with cervical spine injuries

Most cervical spine injuries are due to motor vehicle accidents. Proper extrication of the victims is vital; the ideal device should be easily assembled and applied, should facilitate removal of victims from automobile seats without changing the body's position, must not hinder airway access or the performance of cardiopulmonary resuscitation, must accommodate all types of patients, including children and obese or pregnant patients, and must completely immobilize the patient, especially if hyperextension is suspected. Current methods of immobilization, such as the use of a soft collar and sandbags, allow neck extension; the short board protects against extension but interferes with airway access. Newer devices are discussed in this article. Injuries of the upper cervical spine are less common but more serious than those of the lower portion and usually involve the vertebral arch. Radiologic examination of the first and second cervical vertebrae and the seventh cervical and first thoracic vertebrae should be emphasized. If lateral and anteroposterior views do not reveal abnormal findings and injury is still suspected, oblique views and computed or conventional tomography should be used. Cervical spinal cord injuries can be minimized or prevented if proper early management is applied.

Traumatic cervical radicular lesions

Isolated traumatic cervical radicular lesions are rare. They constitute only 3% of the neurological lesions due to spinal trauma. A monolateral radicular lesion (Type A) is occasionally associated with medullary damage (Type B), resulting in a more complex neurological syndrome. Type A lesions are caused by flexion/rotation with fracture of the upper part of an articular facet and rotatory dislocation of the vertebra above, or by a pure monolateral dislocation. Reduction by halo traction followed by halo plaster gives good results even when the anatomical result is imperfect. Operative treatment of these lesions is required only in cases which cannot be reduced nonsurgically. Type B myelo-radicular lesions are caused by hyperextension-rotation injuries with displaced fractures of the facets and secondary subluxation. The treatment is surgical; reduction by a posterior approach with fixation by Roy-Camille plates, but must include radicular release by removal of the fractured joint mass.

Fractures of the metatarsals: management of complicated injuries with a simple traction system

A simple method of skeletal traction is described to facilitate management of complicated multiple fractures of the metatarsals following crush injuries of the foot. The system uses Brock's pins and a modified Nissen loop to achieve either balanced traction or fixed traction. Satisfactory alignment of the fractures can be maintained whilst soft tissue disorders are dealt with.

[Fractures of the clavicle: classification, diagnosis, therapy]

Clavicular fracture is one of the most frequent skeletal lesions. In most cases the median third of the clavicula is affected (this is due to the peculiar biomechanical structure). Accompanying lesions and complications of clavicular fractures are rare. A total of 13 x-ray diagnostic techniques are described for clavicular fractures. X-ray film should, as a matter of principle, always be taken in two planes. Definitely the major part of clavicular fractures are treated conservatively (rucksack dressing), whereas surgery is reserved for few and strictly defined indications.

Skiers' lower leg shaft fracture. Outcome in 91 cases treated conservatively with Sarmiento's brace

We report our experience using Sarmiento's method for the conservative treatment of 91 consecutive fractures of the lower leg. The mean age of the patients in our series was 34 years. One patient had an open fracture. All of the patients were followed and were evaluated clinically and radiographically 6 to 12 months after injury. After a period of immobilization by traditional methods (traction/long leg cast), the Sarmiento brace was applied at a mean of 42 days, allowing early weightbearing and mobilization. The brace was removed at a mean of 90 days. Clinical results were excellent; there was minimal persistence of knee or ankle limitation; 84% of the patients had less than 5 mm of final shortening; 96% had less than 4 degrees of final angulation. Work was resumed at a mean of 103 days. We had one nonunion, which we treated operatively 6 months after injury by osteosynthesis and autologous bone grafting. All of the patients were asked to complete a questionnaire; 51% responded, with an average followup of 5 years (range, 1 to 10 years). These patients had been able to resume sports activity 8 months after injury; 52% were skiing 1 year after injury, and 96% were satisfied with the treatment method used. One patient complained of persistent pain.

Neurologic injury and recovery patterns in burst fractures at the T12 or L1 motion segment

Fourteen consecutive patients with burst fractures at T12 or L1, partial paralysis, and more than 30% canal compromise were prospectively evaluated pretreatment and posttreatment with roentgenograms to determine the initial fracture pattern, CT scans to determine the percent canal compromise and subsequent improvement, and a quantitative motor trauma index scale and bladder sphincter evaluation to determine neurologic recovery. The follow-up period averaged 32 months (range, 12-50 months). Treatment was as follows: nonoperative (three patients), Harrington rods and fusion (seven patients), and Harrington rods and fusion followed by anterior decompression and fusion (four patients). The initial severity of paralysis did not correlate with the initial fracture roentgenographic pattern or the amount of initial CT canal compromise. Neurologic recovery did not correlate with the treatment method or amount of canal decompression. Subsequent recovery did correlate with the initial fracture pattern. If the patient had a Type I or Type II fracture (both greater than 15 degrees kyphosis), greater than 90% neurologic recovery occurred, regardless of treatment. If the patient had a Type III fracture (less than 15 degrees kyphosis and the maximal canal compromise where bone encircles the canal) less than 50% neurologic recovery occurred. If the patient had a Type IV fracture (less than or equal to 15 degrees kyphosis and the maximal canal compromise at the level of the ligamentum flavum), the neurologic recovery was variable. Prognosis for neurologic recovery can be made based on initial roentgenograms. If greater than 15 degrees kyphosis is present, there is a good prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Slab fractures of the third carpal bone in standardbreds and thoroughbreds: 155 cases (1977-1984)

Case records and radiographs of 155 horses with third carpal bone (C3) slab fractures were reviewed. Of these cases, race records were obtained for 72 Thoroughbreds and 61 Standardbreds. Three performance criteria were examined: ability to make 1 start, ability to make 10 starts or earn $2,000 (within 1 year of first start after the fracture), and earnings per start. Treatment distribution (lag screw fixation, fragment excision, or rest) was similar in both breeds. Significant differences between breeds were identified in age and sex distributions, fracture displacement, and postinjury performance. In Thoroughbreds, there was a tendency for fractures to occur in the right C3 (59%); in Standardbreds, forelimbs were affected equally. The dorsomedial aspect of C3 was the site of fracture in 87% (135/155) of the cases. Horses referred for treatment were predominantly 2-year-old Standardbreds and 3-year-old Thoroughbreds. Females of both breeds were less likely to race after injury than males (46 vs 90%). In Standardbreds, all 38 horses with racing starts before fracture were able to race again. Prior racing starts were not related to outcome in Thoroughbreds. The effects of treatment on outcome were not significantly different. Fracture characteristics did not significantly affect outcome, but did influence treatment selection. Convalescent time was not correlated with any of the variables examined (including treatment) or related to outcome; time from admission to first start averaged 11 months. In STandardbreds, 77% of the horses with C3 slab fracture raced after injury; in Thoroughbreds, 65% raced. Earnings per start declined in each breed, but the decline was more pronounced in Thoroughbreds.

Treatment of scaphoid fractures with a removable cast

Forty-four fractures of the scaphoid bone were treated with a short-term removable orthoplast cast and compared with 48 fractures treated with a conventional long-arm plaster cast. At the follow-up, there was no difference between the two treatment groups as regards nonunion or other sequelae. We conclude that the inconvenience of the treatment of scaphoid fracture and the need of physiotherapy can be reduced by using an orthoplast cast.

Intra-articular fractures of the basilar joint of the thumb

This article on intra-articular fractures of the basilar joint of the thumb discusses the biomechanical and treatment complexities of fractures involving the thumb carpometacarpal joint. This review focuses on the treatment of thumb carpometacarpal fractures and dislocations, consolidating current philosophy and rationale regarding operative and nonoperative treatment. Treatment recommendations are based upon principles established in previous clinical and biomechanical studies emphasizing fracture-specific modalities. Emphasis is placed on maintenance of articular congruity, fracture stability, early motion, and maximum return of function.

Clinical observations on fractures and heterotopic ossification in the spinal cord and traumatic brain injured populations

Fracture care and osteogeneic response deviate significantly from normal in patients with traumatic brain injury (TBI) or spinal cord injury (SCI). In TBI open reduction and internal fixation (ORIF) are recommended whenever possible to improve mobilization in the face of spasticity and the formation of heterotopic ossification (HO). In the patient with SCI, immobility and paralysis negatively alter healing. A fracture above the level of SCI, although not altered in healing, when treated by ORIF will facilitate transfer training and self care. Lower extremity fractures in SCI have a high incidence malunion, delayed union, or nonunion and are best treated by internal fixation. HO occurs in 11% of TBI patients, with the hip, shoulder, and elbow being common sites. Trauma dramatically increases the incidence of HO. In SCI, the incidence of HO is 20%, with most occurring in the hip region. A genetic predisposition to form HO is suspected but not proven.