Outcome after pelvic ring fractures: evaluation using the medical outcomes short form SF-36

Fifty-five multiply injured patients with operatively treated unstable pelvic fractures were evaluated for patient-oriented outcome measures. Forty-six adult patients were eligible to complete the SF-36 medical outcome score and completed the SF-36 eight scale medical outcome score by postal questionnaire at a mean follow up to 2 years. The average Injury Severity Score of the eligible patients was 17.5. The average age of the patients was 32 years and 8 months. Fractures were classified by the Tile classification and there were 13 type B and 33 type C pelvic fractures. Seventy-six per cent of patients responded to the surgery. There was a 14 per cent impairment in physical outcome score and a 5.5 per cent impairment in mental outcome score compared with the normal population. The physical and mental outcome of multiply injured patients with pelvic fractures can be measured objectively.

Calcaneal fractures: operative versus nonoperative treatment

BACKGROUND

The purpose of this report is to compare the late results after operative and nonoperative treatment of intra-articular calcaneal fractures.

METHODS

From 1982 to 1992 we treated 250 calcaneal fractures of which 193 were intra-articular. Because of a change in operative indication, most fractures were treated nonoperatively before 1989 and operatively thereafter. Follow-up was possible at an average of 5.1 years for 124 intra-articular calcaneal fractures. Out of these, two groups of 33 nonoperatively and 30 operatively treated cases were formed matching each other with regard to prognostic parameters. Results were assessed by a clinical score considering pain, gait, footwear, and return to work. Pre- and postoperative tuber joint angle measurements were evaluated for their prognostic significance.

RESULTS

In this series of patients, the only statistically significant advantage of operative therapy was concerning return to work. There was no correlation between tuber joint angle and end results. Only when the extremes of the spectrum (nonoperative and operative cases with tuber joint angle < 0 degrees vs. > 25 degrees) were tested against each other was a significant advantage in the group with near normal joint angles found. Thus, open reduction and internal fixation of intra-articular calcaneal fractures can only be expected to benefit those patients with near anatomic reconstruction.

Zone III fractures of the sacrum. A case report

STUDY DESIGN

Case reports.

OBJECTIVES

To define the radiologic characteristics, management, and results of Zone III fractures of the sacrum.

SUMMARY OF BACKGROUND DATA

Zone III fractures of the sacrum are rare. There are few case reports of longitudinal fractures of the sacrum involving Zone III.

METHOD

The authors report eight (four transverse, four longitudinal) Zone III fractures of the sacrum. Seven patients were treated surgically by posterior sacral decompression with or without transiliac bar fixation, and one neurologically intact patient with undisplaced longitudinal fracture was treated conservatively.

RESULTS

Two neurologically compromised patients had return of normal bladder and rectal function, and another had bladder recovery only. The rest continued to show neurogenic bladder and required intermittent self-catheterization. The patient with bilateral foot drop had partial motor recovery and did not require an ankle-foot orthosis.

CONCLUSIONS

These fractures may be difficult to diagnose in polytraumatized patients and require a high index of suspicion. The longitudinal fractures may not be apparent on anteroposterior radiographs, and computed tomography scan may be necessary for establishing the diagnosis. The transverse fractures may show a characteristic step ladder sign on anteroposterior radiographs when the fracture is displaced severely. Proper lateral radiographs often are difficult to obtain, particularly in obese polytraumatized patients. Routine computed tomography scan may overlook the diagnosis. Therefore 2- to 3-mm computed tomography cuts are recommended, which may show double neural foramina in presence of significant anteroposterior displacement and overriding of the fracture fragments. Sagittal computed tomography reconstructions are useful in evaluating the transverse fractures. Posterior sacral decompression is safe and probably promotes nerve root recovery. Longitudinal fractures may be stabilized satisfactorily by transiliac rod fixation.

[Concomitant injuries after upper ankle joint dislocations]

Functional treatment with the Air Stirrup Ankle Brace recommended by C. N. Stover in 1979 can reduce pathological inversion of the ankle joint. In our retrospective study of 109 patients treated by this kind of ankle brace we found 96 patients (88%) with excellent results. Only 13 patients (12%) reported moderate to good results. To detect and characterize their painful conditions of ankles we did a clinical, radiological and MRI-Investigation. In only 2 cases we found a moderate instability after clinical investigation, anterior stress roentgenogram and talar tilt. By using the MRI-investigation 1.0 Tesla with a 512 x 360 Matrix we could find 10 cases with osteochondral lesions of the ankle. In 7 cases there was separated ossicle in the fibulotalar joint, in 1 case we detected a fracture of the processus anterior tali, in another case we could see a posttraumatic lesion of the talus and calcaneus with bone bruise and at least one osteochondral fracture of the distal tibia. The capability of the MRI to detect particularly osteo-chondral lesions of the talus and the tibiofibular joint was shown in 10 of 13 cases. Therefore we recommend to do an MRI-investigation on all patients after ankle sprain if there are painful conditions within the ankle after conservative treatment.

Comparison of two conservative methods of treating an isolated fracture of the lateral malleolus

We compared two conservative methods of treating Weber B1 (Lauge-Hansen supination-eversion 2) isolated fractures of the lateral malleolus in 65 patients. Treatment by immediate weight-bearing and mobilisation resulted in earlier rehabilitation than immobilisation for four weeks in a plaster cast. There was no significant difference in the amount of pain experienced or in the requirement for analgesics and early mobilisation was not associated with any complications. We therefore advocate early mobilisation for these stable ankle fractures.

Long-term outcomes after lower extremity trauma

Previous studies have shown that over one-quarter of patients who were working before a severe lower extremity fracture had not returned to work by 12 months after injury. Disabilities also persisted in household management, recreation, and social interaction. The objective of this study was to determine whether recovery extended beyond 12 months. Three hundred nineteen patients who were previously working and were treated at three level I trauma centers for a severe lower extremity fracture were prospectively followed at 3, 6, and 12 months after injury. Patients were queried at each follow-up about their work status and completed the Sickness Impact Profile (SIP) at 6 and 12 months. The SIP is a widely used and well validated measure of general health status; it was used in this study to measure functional recovery across several domains of daily living. Patients who had not recovered by 12 months (i.e., 204 who were not working, working with limitations, or had limitations in performing other daily activities as measured by elevated scores on the SIP) were contacted again at 30 months and asked to complete an interview and the SIP. At 30 months, an estimated 82% of the study patients had returned to work (compared to 72% at 12 months). SIP scores improved only slightly from 6.4 at 12 months to 5.7 at 30 months. At 30 months, 64% of the patients had no disability (SIP scores less than 4), 17% had mild disability (SIP scores of 4 to 9), 12% had moderate disability (SIP scores of 10 to 19), and 7% had severe disability (SIP scores of 20 or higher). Although the majority of patients with persistent disabilities at 30 months had residual physical impairments at 12 months, the extent of impairment did not fully explain why some people had and had not recovered at 30 months after injury. The results confirm those of other studies that conclude that overall, outcomes after serious trauma are good when appropriate trauma and rehabilitation care are rendered. However, a minority of patients still report limitations at 30 months after injury, with one-fifth not returning to work.

Intramedullary fixation of metacarpal and proximal phalangeal fractures of the hand

The use of intramedullary fixation for fixation of fractures of the metacarpal and proximal phalanx is reported. Flexible intramedullary rods are used for unstable transverse and short oblique diaphyseal fractures of the proximal phalanx and metacarpal. The fracture site is not opened and the rods are introduced under xray control. The rods are cut flush with the bone so that there is no soft tissue tethering. Intramedullary spacers are used in comminuted metacarpal fractures associated with crush injuries and gunshot wounds. The fracture site is opened and a single rod is placed to fill the intramedullary canal. A supplementary plate may be used to control rotation, and bone graft is usually necessary. A new spacer has been designed that has proximal and distal locking screws to control length and rotation. This also is used routinely with bone graft. The techniques outlined stabilize the fracture site allowing immediate motion postoperatively.

Cerclage fixation for fracture dislocation of the proximal interphalangeal joint

Dorsal fracture dislocations of the proximal interphalangeal joint remain 1 of the most difficult problems in which to obtain an excellent functional outcome. The use of minimally invasive internal fixation techniques improving the biologic healing response and yet providing fracture fragment stabilization has met with greater popularity in recent years. The results of 12 patients treated by the volar cerclage wiring technique are described. At average followup examination of 2.1 years, 11 of 12 patients were noted to have no degenerative joint changes with only 1 patient having evidence of early volar articular surface beaking. Average final active arc of motion at the proximal interphalangeal joint was 89 degrees (range, 72 degrees - 109 degrees). The average degree of extension loss at the proximal interphalangeal joint was 8 degrees (range, 0 degrees - 16 degrees). There were no complications involving implant failure, irritation, or infection. A description of the volar cerclage wire technique is presented. This technique provides the advantage of avoiding fracture fragment stripping, stable restoration of the articular surface, and palmar buttress of the middle phalanx at the proximal interphalangeal joint.

Bony skier's thumb injuries

Avulsion fractures of the ulnar collateral ligament of the thumb metacarpophalangeal joint (bony skier's thumb) may result in chronic instability with pain and weakness of pinch if improperly treated. Management requires an understanding of the relevant anatomy and careful clinical examination including stress testing. Undisplaced, or minimally displaced and stable fractures are treated conservatively, whereas displaced, rotated and unstable fractures require surgical treatment.

Use of the minicondylar plate in metacarpal and phalangeal fractures

The minicondylar plate is used for unstable intraarticular and periarticular fractures of the phalanges and metacarpals to provide stability and to allow early motion. This low profile implant can be placed laterally to avoid injury to the extensor mechanism. The authors retrospectively reviewed 53 consecutive patients from 2 institutions in whom 68 fractures (41 metacarpal and 27 phalangeal) had been treated with 1.5-mm or 2-mm minicondylar plates. Common mechanisms of injury were gunshot wounds, crush injuries, and assault/beatings. Thirty-seven fractures were open, 19 had severe soft tissue injury, and 30 required a bone graft. The followup period averaged 17 months. There were no nonunions or malunions. Sixty-seven complications were associated with 40 fractures in 29 patients: primarily symptomatic plates or pullout (30 complications), extensor lag (13 complications), and infections (8 complications). The complication rate was significantly higher in intraarticular and periarticular fractures also involving the middle 1/3 versus proximal 1/3 fractures; open versus closed fractures; fractures with increased soft tissue injury versus minimal injury; and bone grafted versus nongrafted fractures. Final arc of total active motion, available for 45 fractures, was excellent (> or = 221 degrees) for 17 fractures; good/fair (121 degrees to 220 degrees) for 15, and poor (< or = 120 degrees) for 13. Metacarpal fractures had a significantly higher percentage of excellent results than did phalangeal fractures. Final motion did not correlate significantly with complication rate, severity of soft tissue injury, location in the bone, open versus closed fracture, or use of bone graft. When fractures cannot be restored and stabilized reliably by less invasive methods, the minicondylar plate provides secure fixation and can result in adequate function, even in the presence of severe combined injuries.

Tenolysis and capsulectomy after hand fractures

There are well established operative procedures for salvage of function after fracture healing. When hand therapy measures have not achieved a satisfactory range of motion, it is reasonable to remove any hardware, if present, and lyse tendon adhesions that prevent tendon gliding. The exact cause of restricted motion and the location of adhesions are not always predictable preoperatively, so the surgeon should anticipate additional procedures such as dorsal/palmar capsulectomies in combination with extensor and/or flexor tenolysis. The use of local anesthesia for direct patient input during the procedure offers great advantages. In the ideal situation there should be a demonstrable functional need in a compliant patient with a well healed fracture and workable articular surfaces. Competent hand therapy should be available postoperatively. The patient's main risk is worsening of the situation if surgery is unsuccessful. A marginal finger with poor neurovascular status may be better served by going to arthrodesis or even amputation. Tenolysis and capsulectomy, when indicated, are useful procedures in the salvage of these difficult problems.

Rehabilitation and reintegration of multiply injured patients: an outcome study with special reference to multiple lower limb fractures

In this study a group of 104 multiply injured patients (mean ISS = 34) was examined for physical status and social reintegration. Essentially it was noted that 76 per cent of all patients were able to return back to work, although this appears to be age dependent. Open fractures of the leg seem to be the dominating prognostic factor for reintegration resulting in a disability rate of between 20 and 50 per cent. Disability of more than 80 per cent was only due to major head injury. Apparently reintegration is linked to the pattern of injury and is less related to the overall injury severity. We conclude that trauma care is economically cost effective but also needs further standardization and subsequent outcome analysis.

Early motion protocols in hand and wrist rehabilitation

Early motion programs establish gliding, decrease unwanted adhesions, and enhance the healing process and return to normal function of injuries. This article elaborates on how to best incorporate early motion programs into the rehabilitation process.

Clay as a therapeutic tool in group processing with the elderly

Geriatric rehabilitation includes medical treatment, physical therapy, and therapy in both the psycho-social field and the activities of daily living (ADL). Its objective is to return the individual to independent functioning. This may be achieved through art therapy, which enables verbal and non-verbal communication; the expression of personal feelings; and physical, sensorimotor, and cognitive therapy. Group work with hospitalized elderly people is general limited, and art therapy using clay is particularly so. Yet it can stimulate feelings of fellowship and evoke a sense of cooperation and support. This article reviews group work with clay as an additional form of therapy with a group of 8 patients with Cerebrovascular Accident (CVA), or stroke, and femur neck fractures. The objective of the therapy was to combine bilateral sensorimotor activities of the upper limbs with social interaction directed towards future leisure-time activity. The subject of the clay work was "the home," which is central in the life of the elderly person. The article describes initial group activity with two groups of patients. Analysis of the activity was through retrospective observation--examining videotapes, photographs, and questionnaires at the end of each session.

Early motion in the treatment of fractures and dislocations in the hand and wrist

The concept of early motion is valuable in the treatment of fractures of the hand and wrist. It is a means to an end, however, and should be employed principally when the benefits outweigh the risks. The goal is a hand that functions as near to normally as possible, considering the injury. All treatments need to be tailored to the individual patient.

[Articular fractures of the base of the first metacarpal. Comparative study of direct osteosynthesis and closed pinning]

The authors retrospectively studied 35 articular fractures of the base of the first metacarpal, with an average follow-up of 3 years. Treatment consisted of closed reduction and pinning in 19 cases, open reduction and rigid fixation in 16 cases. Results were estimated in terms of pain, range of movement (flexion-adduction arc and abduction-extension arc), strength and X-rays. There was no significant difference between the two groups, for age, sex, occupation, side and postoperative care. Only one significant difference between both procedures was found: flexion-adduction was better after osteosynthesis than after closed pinning (p = 0.03). The authors observed a better range of flexion-adduction and pinch strength after treatment of Bennett's fracture. Radiographic features were not different at follow-up between open and closed osteosynthesis.

Assessing outcome following calcaneal fracture: a rational scoring system

Six existing clinical scoring systems for assessing outcome after calcaneal fracture are reviewed. All were applied to a diverse group of 75 patients who had sustained this injury. Stepwise multiple regression analysis was used to identify the most relevant variables within these systems. Based on this, a simplified and rational outcome scoring system was devised. This system was then tested on a further group of 41 patients and shown to comply well with the characteristics required of an objective outcome score.

The repair of a ruptured deltoid ligament is not necessary in ankle fractures

We randomised 50 patients with ankle fractures of Weber types B and C and a ruptured deltoid ligament treated by open reduction and internal fixation to two treatment groups to examine the influence of the repair of a ruptured deltoid ligament. No differences were found except for a longer duration of surgery in the repair group. Our findings suggest that a ruptured deltoid ligament can be left unexplored without any effect either on early mobilisation or on the long-term result.

Traumatic fibular shaft fractures in athletes

A direct blow to the leg resulted in fibular shaft fractures in three elite college athletes participating in contact sports. None of the athletes had prior symptoms suggestive of a stress fracture. All three athletes had benign-appearing fractures and were treated nonoperatively. Ultimate healing was delayed, occurring on average at 23 weeks, and each case was complicated by refracture. Fractures of the fibular shaft in athletes may require more aggressive treatment than other simple fractures to allow sufficient healing to withstand the rigors of athletics.

[The use of interference currents in the rehabilitative treatment of patients with fractures of the leg bones]

Interference currents used in early treatment of patients with crural fractures accelarated recovery of the limb functions as a result of stimulation of involuntary muscular activity, reduced tissue adema and increased mobility of the ankle joint.

The Sickness Impact Profile as a tool to evaluate functional outcome in trauma patients

Because the ultimate goal of trauma care is to restore injured patients to their former functional status, reliable evaluation of functional status is needed to assess fully the effectiveness of trauma care. We hypothesized that the Sickness Impact Profile (SIP), a widely used measure of general health status, would be a useful tool to evaluate the long-term functional outcome of trauma patients and that the SIP would identify unexpected problems in the recovery process and groups of patients at high risk for long-term disability. A prospective cohort of 329 patients with lower extremity fractures admitted to three level I trauma centers were interviewed using SIP at 6 and 12 months postinjury. Patients with major neurologic injuries were excluded. Overall SIP scores and each of the component subscores may range from 0 (no disability) to 100. In this series, the mean overall SIP was 9.5 at 6 months and 6.8 at 12 months, compared with a preinjury baseline of 2.5. At 12 months, 52% of patients had no disability (SIP 0 to 3), 23% mild disability (4 to 9), 16% moderate disability (10 to 19), and 9% severe disability ( > or = 20). Disability was widely distributed across the spectrum of activities of daily living, including physical functioning (mean score of 5.5), psychosocial health (mean score of 5.5), sleeping (mean score of 10.0), and work (mean score of 21.0). The SIP scores did not correlate with Injury Severity Score.(ABSTRACT TRUNCATED AT 250 WORDS)