Acute Internal Fixation Research Articles

Le fratture esposte articolari e periarticolari

Exposed articular and periarticular fractures are serious injuries, often resulting from high-energy traumas, associated to high risk of septic complications, functional impairment of the affected limb and not infrequently patient’s life threatening conditions. Their incidence, though low, is however increasing. The patient with exposed fracture presents an associated injury up to one third of cases. The initial evaluation plays a fundamental role both in the identification and treatment of any concomitant injuries, and in the choice of strategy and timing of treatment of the exposed fractures. The presence of a plastic surgeon in the team facilitates the definition of the therapeutic path. The debridement of the lesion is a fundamental time and must be accurate. Stabilization with external fixator is certainly the treatment of choice and can be adopted both as temporary or as a definitive fixation. Soft tissue management is the keystone of the therapeutic pathway of exposed articular and periarticular fractures. The progress made in “orthoplasty” encourages acute internal fixation and immediate coverage—fix and flap, with a significant reduction in infectious risks and improvement of prognosis. In any case, the available evidence about the treatment of these injuries is limited. Proper management requires a multidisciplinary approach, great experience and personalization of the therapeutic path.

Subclavian Vein Thrombosis following Acute Internal Fixation of a Clavicular Fracture

With the recent increase in popularity of early operative fixation for certain clavicular fracture configurations, it is important for orthopaedic surgeons to be mindful of the possible additional risk of thromboembolic complications that may arise as a consequence of an acute injury. We describe the case of a 41-year-old man who presented to our department with a left-sided, middle-third, displaced clavicular fracture. He underwent an acute open reduction and internal fixation, which was complicated by a postoperative subclavian vein thrombosis. This was treated with oral anticoagulation. The thrombus had completely resorbed by 3 months. Five months after surgery, the patient had a full range of movement of the left arm, with no swelling, after having completed a 4000-mile cycle ride. A review of the available literature suggests that the commonest and safest treatment for a subclavian vein thrombosis is subcutaneous unfractionated heparin followed by oral warfarin therapy. The present case report highlights the potential risk of upper limb thrombosis after acute osteo-synthesis of the clavicle and discusses the current evidence with respect to the treatment of upper limb venous thrombosis.

TS11 *ACUTE INTERNAL FIXATION OF PELVIC RING FRACTURES: SAFE AND EFFICIENT

Background: High energy pelvic ring fractures often occur on polytrauma where staged surgery is recommended. The purpose of this study was to evaluate the safety and efficacy of acute pelvic ORIF which is still controversial.Methods: 45‐month retrospective review was performed. All high energy trauma patients requiring internal fixation were included. Patients were acute ORIF (<24 hrs) or late ORIF (>24 hrs). Demographics, ISS, pelvic AIS, 24 hrs pack cell transfusions, physiological parameters, time to OT, angiography requirement, LOS and mortality were recorded. Data is presented as mean ± SD or percentages. Statistical significant was at *p < 0.05.Results: Forty‐six patients met inclusion criteria, seventeen patients had acute definitive ORIF (5.5 hrs to OT) and twenty‐nine late definitive ORIF (5 days to OT). Demographics, (age: 48 ± 22 years vs. 40 ± 14, gender: 82% vs. 79% males), injury severity (ISS: 30 ± 18 vs. 24.5 ± 13, pelvic AIS: 3.7 ± 1 vs. 3.4 ± 1.1) and 24 hrs transfusion requirements (4.7 ± 5 U vs. 6.6 ± 4 U) were not statistically different between groups. Initial shock parameters were significantly worse in the acute group (*SBP 69.7 ± 17 vs. 108 ± 21, *BD −7.35 ± 4 vs. −4.9 ± 1.5, *Lactate 6.67 ± 7 vs. 2.51 ± 1.3). Angiography was used in 18% (3/17) vs. 21% (6/29) of the cases. All acute ORIF patients survived and one (3%) of the delayed ORIF patients died. The shorter hospital LOS was not significant (25 ± 24 vs. 37 ± 32 days) while the ICU LOS was similar 12/19 patients with 2.9 ± 2.5 days vs. 15/27 patients with 3.7 ± 3.6 days).Conclusion: Acute ORIF of unstable pelvic ring fractures could be performed even in severely shocked polytrauma patients. It did not lead to increased ICU LOS and could decrease the hospital LOS.

MANAGEMENT OF SCAPHOID FRACTURES IN PROFESSIONAL AUSTRALIAN FOOTBALLERS

596 Between 1992 and 1998 in the Australian Football League, 15 players sustained new scaphoid fractures. This represents a rate of new injury of 1 per 314 player seasons. Five players during this period suffered complications from non-union of a previous fracture. Literature review reveals that the two recommended acute treatments for this injury in the general population are plaster immobilization for 6-8 weeks and internal fixation. Fixation is best achieved with a Herbert screw and recommended for early return to play or in cases of fracture displacement. In some sports a playing cast has been recommended but this was not possible in Australian Football due to the demands of the game. An option which was able to be taken by some players was to continue to play despite the presence of an ununited fracture. In these cases, the management decisions were similar to those posed by a missed or late presenting scaphoid fracture. The case histories of players will be presented in this paper. Nine players had acute internal fixation performed, with the remainder immobilized for less than the recommended time. The number of weeks missed after initial injury ranged from 0-22 with a median of 6. Two players with acute internal fixation did not achieve union, with the likelihood that early return to play was a contributing factor. Both went on to miss lengthy periods of football subsequent to their initial return. The conclusions of this study include that acute internal fixation with a Herbert screw is usually the treatment of choice in a professional footballer. Irrespective of the method of treatment, return to play before 10 weeks is likely to result in a higher rate of non-union of these fractures. In the short term, a lengthy recovery period is difficult to accept for a professional athlete when there are case histories of players continuing to play with the injury and then developing non-unions with minimal symptoms in the medium-term. The risk of a poor outcome with early return to sport is relatively high and should not be ignored, particularly in younger players.

Fat release after femur nailing in the dog.

Internal fixation of fractures in the first few hours following injury has important advantages. It can diminish continued blood loss, improve patient mobility, and may help avoid pulmonary and cardiovascular complications of multiple trauma. Fear of increased risk of fat embolism has limited its use. We studied the release of fat during intramedullary reaming and nailing of the femur in dogs. Comparing fat release from an intact and a fractured femur in each dog, significantly more triglyceride was released from the intact bone than from the fractured femur. Thus, reaming a fractured bone produces minimal embolization. The presence of a fracture may decompress the pressure in the medullary canal, minimizing the release of fat into the circulation during acute internal fixation. This could help to explain the low incidence of clinical fat embolism syndrome associated with immediate intramedullary nailing of the femur.