Degree Of Soft Tissue Damage Research Articles

Assessment of blood cortisol levels in patients with diabetic foot syndrome

Objective. To study blood cortisol level in patients with diabetic foot syndrome (DFS), to analyze the possibility of using cortisol level as a biochemical criterion of diagnosis and severity of DFS.Materials and methods. A non-randomized study was performed on 59 patients, who were divided into two groups: patients with the 3rd degree deforming arthritis of the knee joint without a history of diabetes mellitus (DM) and patients with DFS. Venous blood was collected on an empty stomach to determine the levels of cortisol, C-reactive protein, glycated hemoglobin, total protein, and hemoglobin.Results. Our data demonstrated that the blood cortisol level was statistically significantly higher (p < 0.05) and higher than normal in the experimental group of patients with DFS (701.69 (626.44; 904.63) nmol/L) when compared with the control group of patients with 3rd degree deforming knee joint arthrosis without a history of DM (423.7 (326.5; 516.20) nmol/L). Blood cortisol levels in patients with DFS decreased statistically significantly in 5 days after the treatment and was 382.26 nmol/L. Body mass index (BMI) (r = 0.946; p < 0.01) correlated with blood cortisol levels in patients with type 2 diabetes and with a complication of DFS. In patients with DFS, determination of blood cortisol content has the greatest diagnostic value as a biochemical criterion of DFS compared with other studied parameters (AUC, 0.915; p = 0.037). Cortisol content in patients with DFS gradually increases with the increase in the classification category of the University of Texas.Conclusion. Determining the level of cortisol in blood can be useful in the diagnosis of DFS, as well as to determine the degree of soft tissue damage of the lower extremities.

РОЛЬ КЛАССИФИКАЦИИ В ОПРЕДЕЛЕНИИ ТАКТИКИ ЛЕЧЕНИЯ ВЫСОКОЭНЕРГЕТИЧЕСКИХ ПОВРЕЖДЕНИЙ НИЖНИХ КОНЕЧНОСТЕЙ

The article discusses the classification of highly energetic injuries of the lower extremities, their role and determining importance in choosing the scope of examination, preoperative treatment and the choice of a treatment method, proposed a new classification of these injuries. Based on the study of the clinical experience of surgical treatment of 239 patients with complex segmental and complex irregular diaphysial fractures of tibia, the high effectiveness of this classification in determining the algorithm of pre- and postoperative management, surgical treatment of patients depending on the degree of bone tissue damage, the size and nature of wounds in open fractures, the degree of soft tissue damage in closed fractures is shown.

Update in combined musculoskeletal and vascular injuries of the extremities.

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient’s medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.

Effect of soft tissue injury and ulnar angulation on radial head instability in a Bado type I Monteggia fracture model.

The effects of soft tissue damage and ulnar angulation deformity on radial head instability in Monteggia fractures are unclear. We tested the hypothesis that radial head instability correlates with the magnitude of ulnar angular deformity and the degree of proximal forearm soft tissue injury in Bado type I Monteggia fractures.We performed a biomechanical study in 6 fresh-frozen cadaveric upper extremities. Monteggia fractures were simulated by anterior ulnar angulation osteotomy and sequential sectioning of ligamentous structures. We measured radial head displacement during passive mobility testing in pronation, supination, and neutral rotation using an electromagnetic tracking device. Measurements at various ligament sectioning stages and ulnar angulation substages were statistically compared with those in the intact elbow.Radial head displacement increased with sequential ligament sectioning and increased proportionally with the degree of anterior ulnar angulation. Annular ligament sectioning resulted in a significant increase in displacement only in pronation (P < .05). When the anterior ulnar deformity was reproduced, the radial head displaced least in supination. The addition of proximal interosseous membrane sectioning significantly increased the radial head displacement in supination (P < .05), regardless of the degree of anterior ulnar angulation.Our Monteggia fracture model showed that radial head instability is influenced by the degree of soft tissue damage and ulnar angulation. Annular ligament injury combined with a minimal (5°) ulnar deformity may cause elbow instability, especially in pronation. The proximal interosseous membrane contributes to radial head stability in supination, regardless of ulnar angulation, and proximal interosseous membrane injury led to significant radial head instability in supination.

Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus.

Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus.

Management of open fractures: part 1

Open fractures have been considered one of the true orthopaedic emergencies by some, however optimal treatment has not been definitively described. Significant debate has focused on the most appropriate method by which to manage open fractures, but general principles of treatment are well established. Principles include fracture classification, antibiosis, irrigation, debridement, wound management and fracture stabilisation. In this first of a two-part series on open fracture management, the initial management of the patient, which should be performed within the first few hours after presentation, is discussed. This includes assessment and stabilisation of the patient, classification of the fracture, antibiotic use and irrigation of the wound. Open fracture classification systems, such as the Gustilo-Anderson scheme, are used to describe the relationship and degree of soft tissue damage, and are designed to correlate with treatment guidelines and prognosis. Systemic antibiotics are a required component of successful treatment, and prompt initiation of these is important. Irrigation is a key component of the effort to prevent infection, and this should be performed using saline solution and low-pressure methods routinely. The remaining principles (debridement, wound management and fracture stabilisation) will be explored in the second article in this series.

Fractures of the tibial shaft

The tibia shaft is the most often fractured long bone of human beings. Among others traffic accidents (37.5 %), falls (17.8 %), sport accidents (30.9 %) and assaults (4.5 %) are typical mechanisms. A brief clinical examination including the correct classification of the fracture pattern and even more important the degree of the soft tissue damage are the most crucial factors for the following therapeutic cascade. This follows a defined algorithm based on the degree of soft tissue damage. As biplanar X-ray diagnostics are obligatory, CT scans are subject to complex fracture patterns and accompanying intraarticular pathologies.The treatment of tibial shaft fractures is the preserve of operative stabilization, which should be done primarily depending on the degree of the soft tissue injury. Here intramedullary methods - especially intramedullary nailing - are the golden standard.The most serious complication of these fractures is the development of a compartment syndrome. This requires rapid diagnosis and an adequate surgical management in order to avoid extensive muscle necrosis with ischaemic contractures and irreversible neurovascular deficits. Apart from postoperative infections, which are the predominant complication especially in open injuries, non union provide typical and late complications which are partly difficult to treat. These should, depending on their type, follow a dedicated treatment algorithm.

Acromioclavicular joint instability: anatomy, biomechanics and evaluation.

Acromioclavicular (AC) joint instability is a common source of pain and disability. The injury is most commonly a result of a direct impact to the AC joint. The AC joint is surrounded by a capsule and has an intra-articular synovium and an articular cartilage interface. An articular disc is usually present in the joint, but this varies in size and shape. The AC joint capsule is quite thin, but has considerable ligamentous support; there are four AC ligaments: superior, inferior, anterior and posterior. The coracoclavicular (CC) ligament complex consists of the conoid and trapezoid ligaments. They insert on the posteromedial and anterolateral region of the undersurface of the distal clavicle, respectively. The coracoid origin of the trapezoid covers the posterior half of the coracoid dorsum; the conoid origin is more posterior on the base of the coracoid. Several biomechanical studies showed that horizontal stability of the AC joint is mediated by the AC ligaments while vertical stability is mediated by the CC ligaments. The radiographic classification of AC joint injuries described by Rockwood includes six types: in type I injuries the AC ligaments are sprained, but the joint is intact; in type II injuries, the AC ligaments are torn, but the CC ligaments are intact; in type III injuries both the AC and the CC ligaments are torn; type IV injuries are characterized by complete dislocation with posterior displacement of the distal clavicle into or through the fascia of the trapezius; type V injuries are characterized by a greater degree of soft tissue damage; type VI injuries are inferior AC joint dislocations into a subacromial or subcoracoid position. The diagnosis of AC joint instability can be based on historical data, physical examination and imaging studies. The cross body adduction stress test has the greatest sensitivity, followed by the AC resisted extension test and the O'Brien test. Proper radiographic evaluation of the AC joint is necessary. The Zanca view is the most accurate view for examining the AC joint. The axial view of the shoulder is important in differentiating a type III AC joint injury from a type IV injury.

Posteriore Zugänge zum Beckenring

The posterior pelvic ring is critical for the mechanical stability of the pelvis. There is considerable variability in the degree of traumatic injury to the posterior pelvis which results in damage to the ligaments, the bones or a combination of these two functional structures. For management of combined posterior and anterior pelvic ring injuries it is crucial to decide which side has to be treated with priority. Surgical approaches for the posterior pelvic ring include transiliacal plate osteosynthesis, local plate osteosynthesis, iliosacral screw ostheosynthesis and spinopelvic stabilization. The degree of soft tissue damage represents an important criterion that should be considered when determining the surgical approach because extensive soft tissue damage often prevents enlarged explorative surgical access. Especially in posterior pelvic ring injuries, soft tissues should be preserved as much as possible because long periods of immobilization in severely injured patients can compromise wound healing. The aim of this paper is to provide an overview of the most commonly used posterior surgical approaches for pelvic ring injuries.

Complex extremity fractures following high energy injuries: The limited value of existing classifications and a proposal for a treatment-guide

Complex extremity fractures have been described as demanding and associated with an increased risk of complications. Since a treatment-guided classification is not currently available, we recommend a new assessment for complex extremity fractures, categorising them into low, moderate and high risk depending on several fracture-related comorbidities. In our experience, the degree of softtissue damage and the overall injury severity are the most critical determinants in deciding whether primary definitive fracture stabilisation is possible or should be delayed. Low-risk complex extremity fractures can be managed according to classic fracture principles, whereas these principles may have limited value in moderate-risk complex extremity fractures. High-risk complex extremity fractures in the polytrauma setting require thorough assessment. In selected cases, primary amputation is a life-saving alternative. We present a new treatment guide taking parameters of local injury severity into account.

Talar dislocations

From 1987-2003, 36 patients were treated for talar dislocation, 27 patients for subtalar, six for total talar, and three patients for peritalar dislocation. Luxatio pedis sub talo: We found 19 medial closed, seven lateral closed and one third degree open subtalar dislocations. Our therapeutic concept provides for immediate reduction, which is possible by closed procedure for the majority of medial dislocations. If there is a tendency to redislocation, we perform talonavicular K-wire transfixation. In the case of irreducibility, open reduction via lateral approach is the rule. The lateral dislocation type is often accompanied by additional fractures of the hindfoot and tarsus, frequently requiring primary open procedures via medial approach. 32 patients were followed-up in whom we found 17 excellent results, ten good, three mediocre and two poor results. With two thirds of the patients, low grade arthrosis at least was observed and two thirds showed a reduced amplitude of motion in one or more talar joints. A definite correlation between arthrosis and reduced function was not established. We did not find talar necroses, persisting instabilities, or redislocations. Luxatio tali totalis: We found three lateral and three medial complete dislocations. The therapeutic concept consists of immediate reduction-only possible by open procedure. A tendency to redislocation requires K-wire transfixation. All patients were followed-up. We found two good and four poor results, with two total and three partial necroses. As a secondary treatment, two lower ankle joint(LAJ) and two upper ankle joint (UAJ) arthrodeses were performed. There were no talectomies, amputations, or infections. Luxatio pedis cum talo: We found three anterolateral UAJ dislocations. Our therapeutic concept provides for immediate reduction. The whole capsular ligament apparatus was reconstructed by primary or secondary treatment, depending on the degree of soft tissue damage. Follow-up showed two excellent results

Posttraumatic Bacterial Infections in Extremities before and after Osteosynthesis in Small Animals

Posttraumatic Bacterial Infections in Extremities before and after Osteosynthesis in Small Animals

Fiberoptic-guided CO2 laser for harvesting of the internal mammary artery.

The internal mammary artery is the preferred conduit in coronary artery bypass grafting. Although most centers use electrocautery to dissect the internal mammary artery, it has several disadvantages. The purpose of this study in a canine model was to evaluate and compare a fiberoptic CO2 laser device versus electrocautery for harvesting the internal mammary artery. In ten mongrel dogs, both internal mammary arteries with their surrounding pedicles, were dissected from the thoracic wall, using a low-current electrocautery for one artery and a continuous wave, fiberoptic-guided CO2 laser (13 watts) for the contralateral vessel. Blood flow through the vessels was measured immediately after dissection. Mean flow through the laser dissected arteries was 71.3 +/- 23.7 ml/min versus 52.9 +/- 16.5 ml/min in those dissected using electrocautery. Histological examination of the chest wall specimens dissected with electrocautery showed the presence of necrosis, edema and hemorrhage surrounding the muscle, while the specimens dissected with the laser revealed only a narrow area of burn on the surgical margins of the muscle. The laser-assisted dissection was more accurate, as easy, and almost as fast as with the use of electrocautery. Stripping of the internal mammary artery with the fiberoptic CO2 laser offers a promising alternative to electrocautery. Owing to its greater accuracy, the laser technique may reduce the likelihood of damaging the endothelial lining of the dissected vessel. By reducing the degree of soft tissue damage, the CO2 laser may also lower the incidence of sternal wound infection and reduce postoperative chest wall pain and dysesthesia.

Upper and lower limb fractures with concomitant arterial injury.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.

POST-TRAUMATIC OSTEOARTHRITIS—A MEDICO-LEGAL MINEFIELD

A consensus view has been obtained from 108 colleagues about four major questions relating to post-traumatic osteoarthritis (OA) posed by a retired judge. In determining the likelihood of OA developing after a fracture, several factors must be taken into account. These include whether the fracture goes through the joint, the resulting angular deformity, the degree of soft tissue damage, the ensuing laxity of the joint, the presence of generalized OA, the involvement of nearby blood vessels supplying the bones of the joint and possibly the degree of immobilization. Lower limb joints are more likely to develop arthritis after injury than arm joints as they carry more load (although it would be wrong to think that arm joints were not load bearing). Occupation is a further factor. Age is thought to be important, with the elderly more at risk immediately, but the younger having longer in which to develop the disease. Younger people are less likely to develop post-traumatic OA, unless there is involvement of the epiphysis or residual angular deformity. Whilst in animals and in some fractures, degenerative changes begin immediately after damage to the joint, in most adults they take at least 2 years. The span is 2-5 years in more severe cases, including fractures of the joint line with a step in the surface, and associated dislocation. Otherwise it may take 10 years. Most of these data are anecdotal or obtained from retrospective surveys. There is great need for prospective work in this field.

Small-animal traumatizer.

Clinical research, particularly among traumatized musculoskeletal patients, has been greatly inhibited by a lack of uniformity in the intensity of the injury. That is, few patients present identical injuries with respect to intensity and degree of soft tissue damage. Hence, researchers have gone to the experimental animal to achieve uniformity to the wound. Few studies, however, have reported effective methods of uniform traumatization. A small-animal traumatizer was developed at Brigham Young University that has proved reliable in producing a uniform contusion of 177 mm2 on the lateral thigh of the anesthetized experimental animal. If the investigator seeks an experimentally induced hematoma that approximates contusions seen clinically, one that is unvarying in every sample, something not available in traumatized patients, the small-animal traumatizer may be an important addition to your laboratory.

Comminuted displaced fractures of the patella

A series of 64 comminuted displaced fractures of the patella is reviewed. Morphologically the fractures can be classified into three groups reflecting the mechanism of injury and the degree of soft tissue damage. All fractures were operated on. Tension band wire was used in 21, partial patellectomy in 33 and total patellectomy in 10 patients. The problem of the management of these fractures is often in making the choice between excision and internal fixation. In this retrospective analysis the results of anterior tension band wire fixation were acceptable even in severe comminuted fractures. Partial excision showed satisfactory results provided that at least three-fifths of the patella could be preserved. Total excision is sometimes clearly unavoidable but should be preceded by sober contemplation whenever considered as the alternative to internal fixation.

Roentgenologic bone changes encountered in frostbite, Korea 1950-51.

The study OF frostbite usually is centered on the damage of soft tissues. Changes which might occur in the underlying bone have been mentioned sporadically in a number of publications, almost exclusively from continental Europe (2–5, 7–10). These publications have concerned themselves primarily with the description of the atrophy supposedly occurring in bone following cold injuries. Occasional instances of calcifying periostitis and rare joint changes are mentioned (2, 5, 7, 9). In a recent article, Edwards and Leeper (1) refer briefly to bone lesions. Systematic studies on the bone changes following frostbite in a large well controlled group have not been reported. The Korean war offered an opportunity to obtain such studies, and the results have been interesting, particularly as far as they pertain to late joint changes. Clinical Material This study is based upon observations on 100 enlisted men who incurred frostbite in Korea between Dec. 6, 1950, and March 5, 1951. The clinical findings in these patients are included in a report by Orr and Fainer (6). The importance of the racial background for the occurrence of the cold injuries has been stressed by these authors. Forty-one per cent of the series were Negro, which is considerably higher than the percentage of exposed Negro troops. The majority of the patients had suffered severe cold injuries as indicated by the degree of soft-tissue damage. Orr's four degrees of frostbite were used for classification of the soft-tissue injury. The first degree consisted of erythema, edema, and superficial desquamation only. The second degree showed vesiculation of partial skin thickness. The third degree involved the full thickness of the skin, extending into varying depths of subcutaneous tissue with or without vesiculation. The fourth degree resulted in damage of the deep structures down to and usually including bone. Many patients had different degrees of involvement in different portions of the body at the same time. Classified according to the most severe degree, the totals show 3 patients with first-degree frostbite, 10 with second-degree, 70 with third-degree, and 17 with fourth-degree frostbite. Sixty-four patients had clinical involvement confined to a portion or all of both feet; in 2 involvement was confined to both hands. In 25 a single foot was involved, and in 1 only one hand. The remaining 8 had various combinations of frostbite of the hands and feet. The overall total showed clinical frostbite of a portion, or all, of the following areas: 80 per cent, right foot; 86 per cent, left foot; 7 per cent, right hand; 8 per cent, left hand. Roentgen Examinations and Findings The majority of the 100 patients on whom the study is based had early roentgen studies.