Diagnostic Performance of a telephone questionnaire for fracture-related infections (FRIs) in open tibia fracture patients in Tanzania

INTRODUCTION

Fracture-related infections (FRIs) are a major cause of trauma-associated morbidity worldwide. In 2018, an expert group supported by the AO Foundation, European Bone and Joint Infection Society developed a consensus definition of FRI. Still, there is limited knowledge on the applicability of this definition in low- and middle-income countries (LMICs). Given the unique barriers that cause low follow-up rates for orthopaedic trauma patients in LMICs, this study aims to evaluate the diagnostic performance of a telephone questionnaire in identifying patients with FRIs after open tibia fracture fixation in Tanzania.

MATERIALS AND METHODS

Patients from a randomized controlled trial investigating the infection prevention benefit of locally applied gentamycin for open tibial fractures were included. Patients completed FRI based telephone questionnaires 7-10 days prior to scheduled follow-ups at 6 weeks, 3 months, 6 months, 9 months, and 1 year. The questionnaire included two "confirmatory" criteria questions for FRI (i.e., open wound and purulent drainage) and three "suggestive" criteria questions (i.e., wound drainage, fever, and warmth). Contingency tests were performed to identify the sensitivity and specificity between answers and adjudicated FRI diagnoses at the corresponding in-person follow-up. Data was analysed using STATA version 15.0 and MedCalc's online diagnostic test calculator.

RESULTS

There were a total of 234 complete questionnaires and 85 unique patients included. The sensitivity and specificity of having any positive answer in the questionnaire was highest at 6 months (100 % and 92.5 %, respectively). For all time-points pooled, sensitivity was 71.4 % and specificity was 93.0 %. Drainage had the highest sensitivity (71.4 %) while fever had the highest specificity (99.6 %). For confirmatory criteria, sensitivity was 14.3 % and specificity was 96.0 %. Contrastingly, the sensitivity for suggestive criteria was higher (71.4 %), with a similar specificity (93.8 %).

CONCLUSION

Our study indicates that telephone questionnaires have adequate diagnostic performance when assessing FRIs. The presence of drainage identified the majority of patients with FRI, and specificities were high across confirmatory and suggestive criteria. Our study is one of the first to evaluate telephone questionnaires as a diagnostic tool for FRIs in patients with open tibia fractures in a LMIC hospital and validates the FRI consensus definition criteria.

Does the OTA Open Fracture Classification Align With the Gustilo-Anderson Classification? A Study of 2215 Open Fractures

OBJECTIVES

To characterize the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) and Gustilo-Anderson classification of open extremity fractures and determine if there is meaningful alignment between these grading systems.

METHODS

DESIGN

Retrospective case series.

SETTING

Level I academic trauma center.

PATIENT SELECTION CRITERIA

Adult patients with at least 1 operatively treated open extremity fracture and surgeon-assigned OTA-OFC and Gustilo-Anderson classification.

OUTCOME MEASURES AND COMPARISONS

Frequency, distribution, and association measures of OTA-OFC category scores and Gustilo-Anderson classification types.

RESULTS

Two thousand twenty-seven patients (mean age, 43.1 ± 17.5 years) with 2215 fractures were included. Gustilo-Anderson type I or II fractures (n = 961; 43%) most frequently had the least severe scores for all OTA-OFC categories. Type IIIA fractures (n = 978; 44%) were most often assigned intermediate scores for OTA-OFC Bone Loss (n = 564; 58%). Type IIIB fractures (n = 204, 9%) were most often assigned intermediate OTA-OFC Skin scores (n = 120; 59%). Type IIIC fractures (n = 72; 3%) were most often assigned the most severe OTA-OFC Arterial score (n = 60; 83%). In the multivariable model, OTA-OFC Contamination scores showed little association (β = 0.05; 95% confidence interval [CI], 0.01-0.09) with Gustilo-Anderson classification severity. Conversely, higher OTA-OFC Arterial (β = 0.50; 95% CI 0.44-0.56) and Skin (β = 0.46; 95% CI, 0.40-0.51) scores were strongly associated with more severe Gustilo-Anderson classifications.

CONCLUSIONS

OTA-OFC Contamination scores were weakly associated with Gustilo-Anderson classification severity for open fractures. The study findings suggest that the current Gustilo-Anderson classification does not adequately account for injury contamination, a known predictor of infection.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Fever after an Open Ankle Fracture - a Surprising Diagnosis]

Fever after an Open Ankle Fracture - a Surprising Diagnosis Abstract. We present the case of a patient with a second-degree open dislocated ankle fracture and a complex wound situation as well as fever in the postoperative course. The man, originally from Nigeria, spent his annual holidays in a rural area of ​​the country, where he sustained a right-sided open dislocation fracture of his ankle in a car accident. After initial rudimentary care in Nigeria, the patient traveled back to Switzerland on his own, where he has been living for the past ten years. Back in Zurich he presented himself to our Department for Emergency Medicine. He was admitted to our Trauma Unit and received surgical care. After dismissal, the patient developed a fever of up to 39 °C and returned to our hospital. We initially assumed the reason for the fever to be a wound infection and therefore escalated an already established antibiotic regimen. Only on the second day after admission we tested the patient for malaria as the surgical wounds looked too clean to be the source of the fever. The patient was tested positive for malaria and transferred to the Department of Infectious Diseases for further treatment where he made a full recovery.

[Treatment of ankle fractures]

Fractures of the ankle joint are among the most frequent fractures encountered in any accident and emergency department. The traditional classification systems, i.e. the Lauge-Hansen- and the Weber classifications, have proven inadequate, when it comes to deciding, whether treatment should be surgical or conservative. About ten years ago, a stability-based classification was proposed in view of the fact, that the stabilisation of osteosynthesis depends on the stability of the ankle joint. The literature shows excellent long-term results for conservatively treated stable ankle joint fractures.

Administration of intravenous antibiotics in patients with open fractures is dependent on emergency room triaging

Background

Recent literature has demonstrated that emergent administration of antibiotics is perhaps more critical than even emergent debridement. Most recent studies recommend patients receive antibiotics no later than 1 hour after injury to prevent infection. The objective of this study is to evaluate the time to antibiotic administration after patients with open fractures arrive to a trauma center depending on triaging team.

Methods

A retrospective study at a level 1 Trauma center from January 2013 to March 2015 where 117 patients with open fractures were evaluated. Patients who presented with open fractures of the extremities or pelvis were considered. Subjects were identified using Current Procedural Terminology (CPT) codes. Patients aged 18 and older were analyzed for Gustilo type, antibiotics administered in the emergency room (ER), presence of an antibiotic allergy, post-operative antibiotic regimen and number of debridements, among others. Additionally, whether a patient was triaged by ER doctors or trauma surgeons (and made a trauma activation) was evaluated. Outcome measurements included time to intravenous (IV) antibiotic administration and time to surgical debridement.

Results

Patients received IV cefazolin a median of 17 minutes after arrival. Eighty-five patients who were made trauma activations received cefazolin 14 minutes after arrival while 24 non-trauma patients received cefazolin 53 minutes after arrival (p = <0.0001). The median time to gentamicin administration for all patients was 180 minutes. Patients not upgraded to a trauma received gentamicin 263 minutes after arrival, while patients upgraded received gentamicin 176 minutes after arrival. There was no statistically significant difference between the timing to cefazolin or gentamicin based on Gustilo type.

Conclusions

Overall, patients that arrive at our institution with open fractures receive IV cefazolin significantly faster when trauma surgeons evaluate the patient. Additionally, delays in gentamicin administration are demonstrated in both triaging groups. This is due to the fact that cefazolin is stocked in the hospital ER, while gentamicin is commonly not due to weight-based dosing requirements precluding a standard dose. Improvements can be made to antibiotic administration of non-trauma patients and those requiring gentamicin via improved education and awareness of open fractures.

Participation in a trial in the emergency situation: a qualitative study of patient experience in the UK WOLLF trial

BACKGROUND

Patients can struggle to make sense of trials in emergency situations. This study examines patient experience of participating in the United Kingdom, Wound management of Open Lower Limb Fractures (UK WOLLF) study, a trial of standard wound management versus Negative Pressure Wound Therapy (NPWT).

METHODS

The aim of the study was to understand the patient's lived experience of taking part in a trial of wound dressings. Interviews drawing on Phenomenology were undertaken with a purposive sample of 20 patients, on average 12 days into their hospital stay from July 2012-July 2013.

RESULTS

The participants were vulnerable due to the emotional and physical impact of injury. They expressed their trial experience through the theme of being compromised identified in categories of being dependent, being trusting, being grateful and being without experience. Participants felt dependent on and trusted the team to make the right decisions for them and not cause them harm. Their hopes for future recovery were also invested within the expertise of the team. Despite often not being well enough to consent to the study prior to surgery, they wished to be involved as much as possible. In agreeing to take part they expressed gratitude for their care, wanted to be helpful to others and considered the trial interventions to be a small component in relation to the enormity of their injury and broader treatment. In making sense of the trial they felt they could not understand the interventions without experience of them but if they received NPWT they developed a strong technological preference for this intervention.

CONCLUSIONS

Patients prefer to be involved in studies within the limits of their capacity, despite not being able to provide informed consent. A variety of sources of knowledge may enable participants to feel that they have a better understanding of the interventions. Professional staff need to be aware of the situated nature of decision making where participants invest their hopes for recovery in the team.

TRIAL REGISTRATION

Current Controlled Trials, ID: ISRCTN33756652 . Registered on 24 February 2012.

Treatment preferences in Turkey for open fracture of the tibial diaphysis

OBJECTIVE

The purpose of this study was to investigate different treatment methods employed by orthopedic surgeons for open tibial fracture in adults.

METHODS

Survey of 12 questions regarding treatment of open tibial fracture was conducted with 285 orthopedics and traumatology specialists in Turkey in personal interviews and using web-based technique.

RESULTS

Of all survey participants, 99.6% responded that tetanus prophylaxis is necessary emergency procedure in cases of adult open tibial diaphysis fracture. In addition, 96.5% considered antibiotics administration necessary, 85.6% also selected irrigation with saline, 55.4% included debridement, and 45.3% temporary fixation. Only 4 (1.3%) respondents did not use aminoglycoside antibiotics. While 29.8% of those surveyed preferred external fixator as a definitive treatment method, 75.8% use intramedullary nail and 13.7% preferred plate method.

CONCLUSION

A wide variation was observed among orthopedics and traumatology specialists in Turkey regarding treatment of open tibial diaphysis fracture in adults. Data obtained from this study together with the available literature may be useful to further develop therapeutic approaches.

Wound botulism after traumatic open fracture in Italy

Seventeen days after a traumatic open fracture, a Clostridium botulinum wound infection was diagnosed, with self-limiting symptoms. This is the first report of wound botulism in Italy and the authors discuss the possible role of aerosolized contamination of the wound prior to hospital admission.

Tibial Tuberosity Avulsion Fracture and Open Proximal Tibial Fracture in an Adult: A Case Report and Literature Review

A displaced tibial tuberosity avulsion fracture associated with an open extra-articular proximal tibial diaphyseal fracture is an uncommon fracture pattern. This case report describes the successful management of such a fracture pattern in a 45-year old male using an open reduction and lag screw fixation of the tuberosity with a minimally invasive reduction and plate fixation of the proximal tibial diaphyseal fracture. A literature search was done to determine the expected clinical outcome of this fracture pattern. This is the first reported adult case of an avulsion fractures of the tibial tuberosity associated with an open proximal tibial diaphyseal fracture successfully treated by an anatomical reduction and fixation of the avulsion fracture of the tibial tuberosity combined with minimally invasive percutaneous plate osteosynthesis of the proximal tibial diaphyseal fractures.

Grade 3C open femur fractures with vascular repair in adults

Grade 3C open femur fractures are challenging injuries with higher rates of complications. This is a retrospective review of grade 3C open femur fractures with vascular repair between 2002 and 2012. Outcomes included initial MESS score, additional injuries, duration of operation, complications, secondary operations or amputations, and social life implications. Thirty-one of 39 total patients were selected for revascularization and fracture fixation based on soft tissue injury and MESS score. The intra-operative approach included temporary arterial shunt replacement, orthopedic fixation, arterial reconstruction venous and/or nerve repair and routine fasciotomies. An external fixation and reverse saphenous vein graft was used in a majority of the patients (respectively; 93.5%, 90.3%). The mean follow up was 5.4 years (range 2.2-10). The decision to amputate versus salvage should be left up to patients and their care teams after discussing options and future possibilities rather than using a scoring system.

Ilizarov external fixator for length salvage in infected amputated nonunions

The technique of compression distraction induced osteogenesis via the Ilizarov external fixator system has been used for a variety of traumatic limb pathologies that necessitate boney union and limb preservation. In this case report, we describe an uncommon scenario were an Ilizarov external fixator was used to treat an infected nonunion following a below knee amputation.

Distal tibial fractures and pilon fractures

Fractures of the distal tibia are often very severe injuries that generally occur in the context of high-energy trauma and present with significant concomitant soft tissue involvement. Open fractures and extensive destruction of the articular surfaces are important challenges to the treating surgeon. In consequence the outcome for distal meta- and epiphyseal tibial fractures depends largely on the severity of the soft tissue injury and its management. Conventionally, tibial pilon fractures require surgical intervention. Conservative treatment would only be considered in some exceptional cases, for example, inoperability of the patient. Controversial discussion of optimal surgical technique and optimal timing of surgery is ongoing. There is broad consensus that soft tissue consolidation must have first priority as this is the basis for both fracture healing and good long-term outcomes. Surgical intervention can be managed as a one-stage or multi-stage procedure to achieve internal or external fracture fixation.

Diagnosis and treatment of limb fractures associated with acute peripheral ischemia

Acute Peripheral Ischemia (API) is the most severe acute complication after both open and closed fractures, as ischemia compromises not only the vitality of the affected limb, but also the patient's life, because metabolic anaerobic changes following ischemia have serious local and general consequences. These explain why early diagnosis of API is very important for the prognosis of the traumatized limb.The authors analyse cases when API was not diagnosed immediately after trauma, but some time after the first examination, due to either low systolic BP or to late onset of API. The patients were analysed concerning the type of the fracture, the reason for delayed diagnosis of API, the moment of API diagnosis and the arterial injury. In all those cases, surgery was performed immediately after API diagnosis, in order to identify and treat the complex injuries(bone and vascular).

[Osteoporotic fractures of the distal radius. What is new?]

The demographic development will result in an increase of up to 30 % of distal radius fractures. There are various therapy options but what is new? Conservative therapy: conservative therapy is reserved for stable fractures only. Osteosynthesis by K-wires: due to low biomechanical stability in older patients, insufficient functional and radiological results were achieved. External fixator: external fixators are used in compound and complex fractures and show better results than K-wire osteosynthesis. Angular stable plate osteosynthesis: with angular stable plates it is possible to achieve good results with complex fractures and they are currently the method of choice. Intramedullary osteosynthesis: intramedullary nails result in a faster functional improvement than angular stable plates but have limitations. New is that 90% of osteoporotic distal radial fractures are treated with angular stable plates which have shown good results in single study groups.

Critical analysis of tibial fracture healing following unreamed nailing

PURPOSE

Unreamed nails have revolutionised the treatment of tibial shaft fractures. Many authors, however, have reported increasing bone healing complications with these implants. Unfortunately, few studies have addressed the factors affecting bone healing after unreamed tibial nailing.

METHODS

One-hundred and sixty tibial fractures in 158 patients (mean age 39.5 years) fixed using unreamed nails were reviewed. There were 78 AO type-A, 65 type-B and 17 type-C fractures (115 closed and 45 open fractures). Twelve patient, injury and surgery variables were analysed for their influence on fracture healing.

RESULTS

Union occurred in all fractures after a mean time of 24.3 weeks. Additional surgery to achieve union, apart from dynamisation, was done in nine (6%) cases. The most important variables affecting healing were the mechanism of trauma (p=0.005), fracture site gap (p=0.01), degree of comminution (p=0.0003), associated soft tissue injuries (p=0.02) and the time to dynamisation (p=0.0001).

CONCLUSIONS

High-energy trauma and fracture comminution have a negative impact on bone union and require close follow-up. It is essential to avoid distraction over three millimetres with unreamed nailing. Dynamisation is advised within ten weeks in axially stable fractures to encourage bone healing and avoid failure of the locking screws.

Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures

PURPOSE

The aim of this study was to compare the results of a new technique for low, multidirectional locked nailing with closed reduction and minimally invasive plating in the treatment of distal tibial metadiaphyseal fractures.

METHODS

Forty-six matched patients were divided according to age, gender, Injury Severity Score, and fracture pattern into group A (expert tibial nailing) and group B (minimally invasive plating). Then, the patients were followed up, and the clinical and radiographic results were retrospectively analysed.

RESULTS

The mean followed-up was 24.7±2.7 months in group A and 25.8±2.8 months in group B. No patient had nonunion, shortening, hardware breakdown, or deep-seated infection. Patients in group A had a significantly shorter mean operating time, hospital stay, full weight-bearing time and union time (76±16.6 vs. 90±20.3 minutes, p=0.000; 5.8±2.1 vs. 8.9±3.1 days, p=0.000; 9.0±1.4 vs. 11.1±1.7 weeks, p=0.000; and 21.3±3.5 vs. 23.1±3.6 weeks, p=0.047, respectively). Three patients in group A and one patient in group B presented with malalignment (p=0.608). The mean Olerud-Molander Ankle score was 89.0±7.1 in group A and 87.6±8.4 in group B (p=0.478).

CONCLUSIONS

Distal tibia metadiaphyseal fractures may be treated successfully with low, multidirectional locked nails or plates. However, low, multidirectional locked nailing may represent a superior surgical option, since it offers advantages in terms of mean operating time, hospital stay, full weight-bearing time and union time.

Initial management of open hand fractures in an emergency department

We retrospectively reviewed the cases of patients with open hand fractures and/or dislocations managed at our institution between 2001 and 2009. The management protocol consisted of irrigation and debridement, reduction (if necessary), splinting, and antibiotics administration in the emergency department. Patients with vascular compromise or severe mangling open wounds were taken to the operating room for treatment. Data regarding demographics, wound size and modified Gustilo-Anderson classification, and timing of interventions were recorded. Included in the study were 145 cases (91 class III, 41 class II, and 13 class I injuries). In 102 cases, definitive and final management took place in the emergency department; in the other 43 cases, additional management took place in the operating room. Antibiotics were administered within 4 hours after injury, and irrigation and debridement were performed within 6 hours. Each of the 2 infections (1.4%) developed in a class III injury. In open hand fractures, particularly type I and type II wounds, the protocol we followed can be appropriate when the injury is not the severe mangling type and does not require acute vascular repair.

Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage

BACKGROUND

This study compares open tibia fractures in US Navy and US Marine Corps casualties from the current conflicts with those from a civilian Level I trauma center to analyze the effect of blast mechanism on limb-salvage rates.

METHODS

Data from the 28,646 records in the University of California San Diego Trauma Registry from 1985 to 2006 was compared with 2,282 records from the US Navy and US Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database for the period of March 2004 to August 2007. Injuries were categorized by Gustilo-Anderson (G-A) open fracture classification. Independent variables included age, gender, mechanism of injury including blast mechanisms, shock, blood loss, prehospital time, procedures, Injury Severity Score, length of stay, and Mangled Extremity Severity Score (MESS). Dependent variables included early or late amputation and mortality.

RESULTS

The civilian group had 850 open tibia fractures with 45 amputations; the military group had 21 amputation patients (3 bilateral) in 115 open tibia fractures. Military group patients were more severely injured, more likely have hypotension, and had a higher amputation rate for G-A IIIB and IIIC fractures then civilian group patients. Blast mechanism was seen in the majority of military group patients and was rare in the civilian group. MESS scores had poor sensitivity (0.46, 95% confidence interval: 0.29-0.64) in predicting the need for amputation in the civilian group; in the military group sensitivity was better (0.67, 95% confidence interval: 0.43-0.85), but successful limb salvage was still possible in most cases with an MESS score of ≥7 when attempted.

CONCLUSION

Despite current therapy, limb salvage for G-A IIIB and IIIC grades are significantly worse for open tibia fractures as a result of blast injury when compared with typical civilian mechanisms. MESS scores do not adequately predict likelihood of limb salvage in combat or civilian open tibia fractures.

Adult trauma: getting through the night

It is now recognized that the treatment of many orthopaedic injuries can be, and in many cases should be, deferred until a later date. For example, surgical repair of most fractures of the proximal and distal tibia is now delayed until soft-tissue healing has occurred. Acute treatment involves only provisionally reducing and stabilizing such fractures using a joint-spanning external fixator. However, situations occur in the emergency department in which emergency treatment, even if it is just temporizing in nature, must be done immediately. Often, such treatment is outside the comfort zone of the responsible orthopaedic surgeon, even physicians with training and experience in orthopaedic trauma. Orthopaedic surgeons will benefit from updated information on current methods for the emergency management of limb- and/or life-threatening injuries in adults. Such treatment is often provisional in nature, treating only the urgent component of the injury (such as a compartment syndrome associated with a complex tibial plateau fracture). It is important for orthopaedic surgeons to understand how to get "through the night" so that later appropriate definitive care is facilitated to optimize patient outcomes.

The distal superficial femoral arterial branch to the sartorius muscle as a recipient vessel for soft tissue defects around the knee: anatomic study and clinical applications

Complex wounds surrounding the knee and proximal tibia pose a significant challenge for the reconstructive surgeon. Most of these defects can be managed using local or regional flaps alone. However, large defects with a wide zone of injury frequently require microvascular tissue transfers to aid in soft tissue coverage and closure of large cavities. We describe a unique recipient vessel for microvascular anastomosis for free flap reconstruction involving the knee and proximal tibia through anatomic and clinical studies.

Reconstruction of soft tissue after complicated calcaneal fractures

A total of 35 flap reconstructions were done to cover exposed calcaneal bones in 31 patients. All patients had calcaneal fractures, 19 of which were primarily open. Soft tissue reconstruction for the closed fractures was indicated by a postoperative wound complication. A microvascular flap was used for reconstruction in 21 operations (gracilis, n = 11; anterolateral thigh, n = 5; rectus abdominis, n = 3; and latissimus dorsi, n = 2). A suralis neurocutaneous flap was used in eight, local muscle flaps in three, and local skin flaps in three cases. The mean follow-up time was 14 months (range 3 months-4 years). One suralis flap failed and was replaced by a latissimus dorsi flap. Necrosis of the edges that required revision affected three flaps. Deep infection developed in two patients and delayed wound healing in another four. During the follow-up the soft tissues healed in all patients and there were no signs of calcaneal osteitis. Flaps were considered too bulky in five patients. Soft tissues heal most rapidly with microvascular flaps. In the long term, gracilis muscle covered with free skin grafts gives a good contour to the foot. The suralis flap is reliable and gives a good final aesthetic outcome. Local muscles can be transposed for reconstruction in small defects.

Can patterns of segmental injuries of the foot and ankle predict amputation and disability?

The purpose of the study was to determine the risk of digital or distal segmental amputation and permanent unemployment in patients with these injury patterns. A retrospective chart review of 23 patients with multiple, ipsilateral injuries of the foot and ankle was performed. Amputations occurred in five patients (21.7%) and were most common in those with three-level injuries. Odds ratios showed that patients with an amputation were 9.75 times more likely to have a three-level injury than a two-level injury. At a mean follow-up of 12.9 months, 12 patients had not returned to work (60%), seven returned with restrictions, and only one patient returned to preinjury activities. It was concluded that patients with segmental foot and ankle injuries are at risk for amputation of the distal portion of the involved extremity and inability to return to their preinjury employment level (disability).

The use of frame fixation in the management of open distal extensor mechanism avulsion fracture in a dislocated knee

An avulsion fracture of the tibial tubercle is a common injury in traffic accident. If the fracture is closed, then a comparatively good prognosis can be expected through reinforcement of the bone via osteosynthesis and the use of artificial ligaments. In this case, an open wound was observed in the tibial tubercle, and the wound was so polluted that the healing process was significantly delayed. It was therefore difficult to provide simultaneous surgical treatment and so three operations were required to perform the reconstruction of the extensor mechanism. The reconstruction of extensor mechanism and the frame fixation between the patella and tibia was performed. Six months after the injury, the patient was able to walk without aid, had a range of movement from 5 degrees to 130 degrees , and did not show any indications of ADL disorder. Using this method of frame fixation between the patella and tibia proved to be an effective technique for the reconstruction of the open knee extension mechanism injury.

Tibia fractures. An overview of evaluation and treatment

The purpose of this article is to increase the reader's knowledge of tibial fractures, which are infrequently life threatening but are often life changing. The focus is on the continuum of care, starting with the mechanism of injury, classification of the tibial fracture and soft tissue involvement, approaches to stabilization and treatment options, postoperative care, potential complications, and considerations to discharge preparation. The parameters of nursing care extend to pain relief and positioning, nerve and vascular assessments, safe mobility, self-care, and prevention of complications.

Acute Complications of Extremity Trauma

In addition to the large number of patients with isolated limb injuries, many patients with major blunt or penetrating trauma harbor extremity injuries as a component of their overall clinical picture. Extremity injuries range from gross deformities and amputations to more subtle injuries, potentially difficult to diagnose, or may escape detection in unconscious or intoxicated patients. However, many soft tissue and vascular injuries require time sensitive interventions to ensure salvage of the limb and the best outcome for the patient. This article reviews the acute management of vascular and soft tissue injuries in the emergency department.

The accuracy of the saline load test in the diagnosis of traumatic knee arthrotomies

OBJECTIVES

When open joint injury is suspected in a knee laceration, the saline load test has been recommended as a diagnostic modality, especially in small wounds, where inspection and palpation cannot confirm joint violation. The goals of this study are: 1) to correlate fluid volume needed for positive diagnosis with demographic factors, 2) to assess the sensitivity of using the commonly recommended volume of 50 mL, and 3) to identify the minimum fluid volume necessary to obtain 95% sensitivity.

DESIGN

Prospective cohort.

SETTING

University medical center.

PATIENTS/PARTICIPANTS

Thirty consecutive patients scheduled for elective outpatient knee arthroscopy were prospectively enrolled. Exclusion criteria include history of open traumatic injury, presence of active infection, or limited range of motion as evidence of arthrofibrosis.

INTERVENTION

A standard lateral parapatellar portal was made with a no. 11 blade scalpel, and a 5.8 mm diameter cannula-trochar was inserted and withdrawn to create a standard arthrotomy size of 26.4 mm. Using an 18-gauge needle, saline was injected through a separate lateral suprapatellar site until outflow was noted.

MAIN OUTCOME MEASUREMENTS

Upon fluid outflow, the volume of injected saline was recorded.

RESULTS

The volume injected until outflow was similar between men and women (P = 0.87). No correlation was observed between the volume injected and age (P = 0.85), height (P = 0.18), weight (P = 0.46), and body mass index (P = 0.91). Injection of 50 mL successfully identified only 46% of known arthrotomies. A saline load of 194 mL was required to achieve 95% sensitivity.

CONCLUSIONS

For small lacerations around the knee, saline loads of less than 194 mL are of questionable sensitivity, and surgeons should not use the saline load test to rule out open knee injuries.

Traumatic bitemporal hemianopia

A 45-year-old male pedestrian was struck by a motor vehicle moving at high speed. Upon initial assessment, the patient scored a 3T on the Glasgow Coma Scale. The patient suffered multiple facial and sinus fractures, a right orbital wall fracture, and a depressed open frontal skull fracture with visible brain parenchyma. Due to the nature of the brain injury, the patient was taken to the operating room emergently for a right frontal craniectomy. The patient required prolonged hospitalization followed by transfer to a rehabilitation facility. Six weeks after the accident, the patient underwent an extensive neuro-ophthalmologic evaluation. At that time, visual acuity was 20/200 in both eyes. On visual field testing, a bitemporal hemianopia was noted. Ophthalmoscopic examination revealed bilateral temporal disc pallor, right greater than left. Neuroimaging demonstrated damage to the optic chiasm. Although rare, head trauma may cause a bitemporal hemianopia secondary to optic chiasmal injury.

Subatmospheric pressure dressings in the temporary treatment of soft tissue injuries associated with type III open tibial shaft fractures in children

PURPOSE

This study was designed to evaluate the use of subatmospheric pressure dressings on high-energy open tibial shaft fractures in children. We hypothesized that the use of a negative-pressure dressing in these fractures would result in a decreased incidence of infection and decreased need for pedicled muscle flaps and free tissue transfer.

METHODS

A retrospective case series of 15 consecutive pediatric patients with 16 type III open tibial shaft fractures (8 type IIIA, 7 type IIIB, and 1 type IIIC). The patients' age ranged from 2 to 17 years. All patients underwent a standard protocol of serial irrigation and debridement of the open wound with bony stabilization. Temporary coverage of the open wound was obtained with the use of a subatmospheric pressure dressing until definitive wound coverage or closure.

RESULTS

Infection occurred in 5 of 16 fractures, 2 requiring antibiotics alone (1 type IIIA and 1 type IIIB) and 3 requiring surgical intervention (2 type IIIB and 1 type IIIC). Seven of 16 (3 type IIIA, 3 type IIIB, and 1 type IIIC) fractures required repeat surgical intervention to facilitate bony healing. Only 3 patients required free tissue transfers or rotational muscle flaps for coverage, a 50% decrease compared with the initial classification.

CONCLUSIONS

Compared with other described methods, the use of subatmospheric pressure dressings in the temporary treatment of soft tissue wounds associated with high-energy open tibial shaft may reduce the need for major soft tissue coverage procedures. Its effect on infection and fracture healing rates requires further study.

SIGNIFICANCE

A reduction in the need for major soft tissue coverage procedures with the use of negative-pressure dressings in this setting should result in decreased morbidity for these patients and in decreased social and financial costs.

[Compound depressed fracture of occipital bone causing laceration of left occipital lobe and injury of superior sagittal sinus--case report]

A case of compound depressed fracture of occipital bone in 52-years old man caused by crane hook is presented. Bone fragments were depressed 40 millimetres causing blindeness and huge hemorrhage with symptoms of hemorrhagic shock. Laceration of left occipital lobe and penetration of superior sagittal sinus were treated during the operation. Primary elevation, debridement and primary bone replacement with additional covering of bone defect by bone cement were performed. Primary wound healing was achieved. Cortical blindeness subsided to the stage of contralateral homonymous hemianopia.

[Small bowel perforation caused by compound pelvic fracture found in diagnostic laparoscopy]

Small bowel perforations in blunt abdominal trauma (BAT), especially in multiply injured patients, are difficult to diagnose in the first hours after the accident, either clinically or by imagistic studies. A less encountered diagnostic modality is diagnostic laparoscopy (DL), selectively indicated. We present the case of a patient with BAT and complex pelvic fracture, hemodynamically stable, with TS= 15, who clinically had abdominal tenderness and on ultrasound (US) and CT scan, had free intra-abdominal fluid (FIAF), without any injuries of a solid viscus, which led us to suspect a hollow viscus injury. We proceeded with a DL, imposed by the equivocal diagnosis, taking advantage of the general anesthesia needed for the femoral and pelvic fracture immobilization. We identified an ileal perforation and decided to convert to open surgery, and we found a second perforation. Segmentary ileal resection was performed. Orthopedically, in emergency, the femoral fracture and the posterior arch of the pelvis were immobilized, but due to the septic risk, the anterior arch was immobilized 10 days later. DL is a valuable tool in BAT with FIAF on US and CT scan with suspicion of hollow viscus perforation in the hemodynamically stable patients, in order to decide between laparotomy and observation. In equivocal diagnosis cases, DL avoids unnecessary or delayed laparotomy. Whenever possible and indicated, orthopedic lesions will be dealt with in emergency ("early total care"), in order to reduce the recovery and hospitalization period.

Functional outcome and quality of life of Gustilo IIIB open tibial fractures requiring free tissue transfers: a report of eight cases

Eight patients with type IIIB open tibial fractures requiring free tissue transfers were retrospectively reviewed. The functional outcome was evaluated by using a scoring system developed by Puno et al. (Microsurgery 17:167-173, 1996). Short Form 36 (SF-36) was used as a measurement of individuals' quality-of-life (QOL) scores. The average total score of all cases was 77.6. An excellent or good functional outcome was achieved in 37.5% (3/8). Six patients were evaluated by SF-36. The average physical health summary (T-PH) score was 47.9, the average mental health summary (T-MH) score was 53.5, and the average total general health summary (T-GH) score was 50.7. The mean T-MH score was significantly higher than the mean T-PH score (P < 0.05). Treated cases showed an acceptable QOL, considering the results of the T-GH. The mental QOL was higher than the physical QOL. In severe open tibial fractures, it is difficult to obtain a good or excellent functional outcome, even with reconstruction using free tissue transfers.

Base of distal phalanx fracture in children: a mallet finger mimic

The authors present a series of seven juxtaepiphyseal fractures at the base of the distal phalanx of the finger. Prior to closure of the epiphysis, the fracture line is usually through the growth plate (Salter-Harris type I or II) or 1 to 2 mm distal to the plate. Clinically the injury looks like a mallet finger, but the pathoanatomy is not that of the classic mallet. All seven of these fractures were treated by closed reduction, six fractures were fixed by a Kirschner wire, and one was held by splinting only. All healed without complications.

Pelvic fractures and high energy traumas

Pelvic fractures are associated with a high mortality and morbidity and their presence should be considered in all high energy traumas. Early management is directed towards basic advanced trauma life support (ATLS) principles but it is essential to be aware of the diagnosis and management of these complex injuries.

The application of dermatotraction for primary skin closure

Management of an open wound is a problem frequently encountered in the treatment of fractures. Skin grafting, rotational flaps, free flaps, and healing by secondary intention add a considerable amount of morbidity and cost to the patient. Therefore, it is ideal to obtain primary closure when possible. This communication describes a technique that uses spinal needles, using towel clips and the natural stretching ability of the skin to enable primary closure of wounds. The technique described uses dermatotraction to stretch the skin is a cost-effective way to achieve primary closure of large wounds with supplies that are readily available in every operating room.

Orthopaedic trauma for the general orthopaedist: avoiding problems and pitfalls in treatment

The Advanced Trauma Life Support program of the American College of Surgeons has developed a de facto standard of care for the first hour of treatment of patients with trauma who are treated in North America. No equivalent for the treatment of orthopaedic trauma has been established. We provide an overview of the important topics every orthopaedist treating patients with musculoskeletal trauma should be familiar with. The topics include: (1) diagnosis of musculoskeletal injury and documentation of physical exam; (2) pelvic ring injuries; (3) open fractures; (4) compartment syndrome; (5) the timing of definitive fixation in the patient with polytrauma; (6) delayed diagnosis of musculoskeletal injury; and (7) deep venous thrombosis prophylaxis.

The treatment of chronic open osteomyelitis of the tibia in adults

The treatment of 30 consecutive adult patients with chronic draining osteomyelitis of the tibia was reviewed. There were four treatment patterns. Eight patients had local debridement with or without soft tissue coverage procedures or bone graft. Three patients had radical debridement and bone transport using a circular frame. Eight patients were treated by the Papineau grafting technique after debridement. Eleven patients had debridement and circular frame fixation to correct associated nonunion, malunion, or shortening. All patients received long-term antibiotic therapy. At an average of 6 years' followup (minimum, 2 years), two patients had persistent drainage and one patient had an aseptic nonunion. This experience affirms the value of the circular frame, of the Papineau graft, of bone transport, and of long-term antibiotics for treatment of chronic osteomyelitis of the tibia. There was successful limb salvage in all of the patients and successful treatment (fracture healing without drainage) in 27 of 30 patients.

LEVEL OF EVIDENCE

Therapeutic study, Level III-1 (case-control study). See the Guidelines for Authors for a complete description of levels of evidence.

Pediatric fractures of the forearm

Forearm fractures are common injuries in childhood. There are a number of important principles that should be followed to achieve the ideal goal of fracture healing without deformity or dysfunction. I will review the general principles, classifications, diagnosis, treatment, and complications of pediatric forearm fractures, including some specific injuries such as Monteggia fractures, Galeazzi injuries, and open fractures. The basic principle is to accurately align the fracture fragments and to maintain this position until the fracture is united. Forearm fractures in children can be treated differently from adult fractures because of continuing growth in both bones (radius and ulna) after the fracture has healed. As long as the physes are open, remodeling can occur. However, generally it is thought that rotational deformity does not remodel. Undisplaced fractures may be treated in a cast until the fracture site is no longer painful. Most displaced fractures of the forearm are best maintained in a long arm cast. However, redisplacement occurs in 7 to 13% of cases, usually within 2 weeks of injury. Unstable metaphyseal fractures should be percutaneously pinned. Unstable diaphyseal fractures can be stabilized by intramedullary fixation of the radius and ulna. If none of these techniques is helpful, plate and screw fixation is the best choice.

Open pelvic fractures: epidemiology, current concepts of management and outcome

Open pelvic fractures constitute one of the most devastating injuries in musculo-skeletal trauma and must be treated aggressively, incorporating a multidisciplinary approach. Early treatment, focusing on prevention of haemorrhage and sepsis, is essential. The management of associated soft tissue injuries must also be aggressive, including early administration of broad-spectrum antibiotics and repeated, meticulous wound debridement and irrigation. Selective faecal diversion, based on wound location, is compulsory and safe, minimising the risk of sepsis and reducing mortality rates.

Composite vascularised osteocutaneous fibula and sural nerve graft for severe open tibial fracture--functional outcome at one year: a case report

Management of severe open tibial fracture with neurovascular injury is difficult and controversial. Primary amputation is an acceptable option as salvaging the injured, insensate, and ischaemic limb may result in chronic osteomyelitis and non-functional limb. We report a case of open tibial fracture associated with segmental bone and soft tissue loss, posterior tibial nerve and artery injuries, which was further complicated by chronic osteo-myelitis treated with composite vascularised osteocutaneous fibula and sural nerve graft. Functional outcome of the injured limb at one-year follow-up was satisfactory: the patient was capable of achieving full weightbearing and was able to appreciate crude touch, pain, proprioception, and temperature at the plantar aspect of the foot. There was no pressure sore or ulceration.

Treatment of the mangled lower extremity after a terrorist blast injury

Terrorist bombings, with resultant blast injuries, have been increasing in frequency during the past 30 years. Injury to the musculoskeletal system is common in victims who survive such attacks. Substantial injury to the limbs may occur through several different mechanisms, each of which may affect prognosis and alter the treatment algorithm. An analysis of the available literature on terrorism and blast events revealed that resource use of the treating medical facility is high during the initial hours after a blast attack, but usually is manageable. A resource management protocol was developed to organize the treatment of limb salvage into four phases. This management protocol may improve the medical facility's ability to manage system resources while treating patients with severe blast injuries. The decision of whether to salvage or proceed with limb amputation is one of the most difficult in orthopaedic trauma. A basic education in the mechanisms of blast damage, a methodical approach to resuscitation, and mangled extremity treatment, likely can improve surgical success.

Open bicondylar Hoffa fracture associated with extensor mechanism injury

Two cases of open bicondylar Hoffa fracture of the knee associated with extensor mechanism injury are described in two active young patients with multiple fractures. The level of the fracture was determined by the proximal insertion of the posterior cruciate ligament and anterior cruciate ligament in the medial and lateral condyle. The level of the extensor mechanism injury was determined by the degree of flexion of the knee at the moment of impact. No ligament or meniscal tears were found. Open reduction and internal fixation with four lag screws and bone-to-tendon repair of the patellar and quadriceps tendon gave excellent results after more than 2 years of follow-up. The mechanism of injury and the therapeutic implications are discussed, and the literature is reviewed.