Operative Stabilization Of Fractures Research Articles

Optimal timing of stabilization and operative technique for extremity fractures in polytrauma patients: a systematic review and meta-analysis

PurposeIn polytrauma patients, injuries involving the extremities are frequently seen. Treatment concepts vary from early definitive care to temporary fixation and delayed definite stabilization. This analysis therefor aims to illuminate the impact of timing for operative stabilization of extremity fractures on outcome factors in adult polytrauma patients.MethodsWe searched PubMed and Cochrane CENTRAL to identify studies from inception of each database to 14 September 2022. We included systematic reviews and RCTs comparing immediate versus delayed operative fracture stabilization and early definite care versus primary external fixation in adult polytrauma patients.ResultsFive randomized controlled trials were included, with a total of 335 patients. The analysis found no statistically significant difference in overall mortality or improvement in ICU admission between early (< 24 h) and late fracture stabilization. Comparing femoral nailing and external fixation, findings showed that femoral nailing reduce ICU length of stay and duration of invasive mechanical ventilation.ConclusionThe results indicate that immediate surgical treatment by nailing is superior to delayed treatment or a staged surgical approach in stable polytrauma patients with long-bone fractures. As there is a lack of clear evidence regarding the optimal timing for definitive operative stabilization of extremity fractures in polytrauma patients, further high-quality studies are essential to enhance the certainty of evidence and provide more conclusive treatment algorithms.

Does Surgical Stabilization of Lateral Compression-type Pelvic Ring Fractures Decrease Patients' Pain, Reduce Narcotic Use, and Improve Mobilization?

Debate remains over the role of surgical treatment in minimally displaced lateral compression (Young-Burgess, LC, OTA 61-B1/B2) pelvic ring injuries. Lateral compression type 1 (LC1) injuries are defined by an impaction fracture at the sacrum; type 2 (LC2) are defined by a fracture that extends through the posterior iliac wing at the level of the sacroiliac joint. Some believe that operative stabilization of these fractures limits pain and eases mobilization, but to our knowledge there are few controlled studies on the topic. (1) Does operative stabilization of LC1 and LC2 pelvic fractures decrease patients' narcotic use and lower their visual analog scale pain scores? (2) Does stabilization allow patients to mobilize earlier with physical therapy? This retrospective study of LC1 and LC2 fractures evaluated patients treated definitively at one institution from 2007 to 2013. All patients treated surgically, all nonoperative LC2, and all nonoperative LC1 fractures with complete sacral injury were included. In general, LC1 or LC2 fractures with greater than 10 mm of displacement and/or sagittal/axial plane deformity on static radiographs were treated surgically. One hundred fifty-eight patients in the LC1 group (107 [of 697 screened] nonoperative, 51 surgical) and 123 patients in the LC2 group (78 nonoperative, 45 surgical) met inclusion criteria. The surgical and nonoperative groups were matched for fracture type. To account for differences between patients treated surgically and nonoperatively, we used propensity modeling techniques incorporating treatment predictors. Propensity scores demonstrated good overlap and were used as part of multiple variable regression models to account for selection bias between the surgically treated and nonoperative groups. Patient-reported pain scores and narcotic administration were tallied in 24-hour increments during the first 24 hours of hospitalization, at 48 hours after intervention, and in the 24 hours before discharge. Time from intervention to mobilization out of bed was recorded; intervention was defined as the date of definitive surgical intervention or the day the surgeon determined the patient would be treated without surgery. There was no difference in the narcotics distributed to any of the groups with the exception that the patients with surgically treated LC2 fractures used, on average (mean [95% confidence interval]) 40.2 (-72.9 to -7.6) mg morphine less at the 48-hour mark (p = 0.016). In general, there were no differences between the groups' pain scores. The surgically treated patients with LC1 fractures mobilized 1.7 (-3.3 to -0.01) days earlier (p = 0.034) than their nonoperative counterparts. There was no difference in the LC2 cohort in terms of time to mobilization between those treated with and without surgery. There were few differences in pain scores and morphine use between the surgical and nonoperative groups, and the differences observed likely were not clinically important. We found no evidence that surgical stabilization of certain LC1 and LC2 pelvic fractures improves patients' pain, decreases their narcotic use, and improves time to mobilization. A randomized trial of patients with similar fractures and similar degrees initial displacement would help remove some of the confounders present in this study. Level III, therapeutic study.

Stabilization of multiple rib fractures in a canine model

BackgroundOperative stabilization is frequently used in the clinical treatment of multiple rib fractures (MRF); however, no ideal material exists for use in this fixation. This study investigates a newly developed biodegradable plate system for the stabilization of MRF. MethodsSilk fiber-reinforced polycaprolactone (SF/PCL) plates were developed for rib fracture stabilization and studied using a canine flail chest model. Adult mongrel dogs were divided into three groups: one group received the SF/PCL plates, one group received standard clinical steel plates, and the final group did not undergo operative fracture stabilization (n = 6 for each group). Radiographic, mechanical, and histologic examination was performed to evaluate the effectiveness of the biodegradable material for the stabilization of the rib fractures. ResultsNo nonunion and no infections were found when using SF-PCL plates. The fracture sites collapsed in the untreated control group, leading to obvious chest wall deformity not encountered in the two groups that underwent operative stabilization. ConclusionsOur experimental study shows that the SF/PCL plate has the biocompatibility and mechanical strength suitable for fixation of MRF and is potentially ideal for the treatment of these injuries.

A micro-architectural evaluation of osteoporotic human femoral heads to guide implant placement in proximal femoral fractures

Background and purpose The micro-architecture of bone has been increasingly recognized as an important determinant of bone strength. Successful operative stabilization of fractures depends on bone strength. We evaluated the osseous micro-architecture and strength of the osteoporotic human femoral head.Material and methods 6 femoral heads, obtained during arthroplasty surgery for femoral neck fracture, underwent micro-computed tomography (microCT) scanning at 30 μm, and bone volume ratio (BV/TV), trabecular thickness, structural model index, connection density, and degree of anisotropy for volumes of interest throughout the head were derived. A further 15 femoral heads underwent mechanical testing of compressive failure stress of cubes of trabecular bone from different regions of the head.Results The greatest density and trabecular thickness was found in the central core that extended from the medial calcar to the physeal scar. This region also correlated with the greatest degree of anisotropy and proportion of plate-like trabeculae. In the epiphyseal region, the trabeculae were organized radially from the physeal scar. The weakest area was found at the apex and peripheral areas of the head. The strongest region was at the center of the head.Interpretation The center of the femoral head contained the strongest trabecular bone, with the thickest, most dense trabeculae. The apical region was weaker. From an anatomical and mechanical point of view, implants that achieve fixation in or below this central core may achieve the most stable fixation during fracture healing.

Role of Enders Nail In Diaphyseal Fractures of Long Bones in Pediatric Age Group

BACKGROUND: The need for operative fixation of paediatric diaphyseal fractures is increasingly being recognized in the present decade. The conventional traction and casting method for management of pediatric diaphyseal fractures is giving way for the operative stabilization of fractures. Methods: 28 pediatric patients in the age group 6-14 years with diaphyseal fractures were stabilized with minimum of two Enders nails. Patients were followed up clinically and radiologically for 2 years. The final results were evaluated using the criteria of Flynn et all. Technical problems and complications associated with procedures were also analyzed. Results: Overall results observed were excellent in 23, satisfactory in 5, and no poor results. Hospital stay averaged 10 days in the series. All fractures healed with an average time to union of 6 weeks. The soft tissue discomfort near the knee joint produced by the nailing was the most common problem encountered. Shortening was observed in two cases and restriction of knee flexion in 2 cases. There was no delayed union, infection or refractures. Per operative technical problems included failure of closed reduction in 6 cases. Residual angulation occurred in two cases of with the medial C and S construct, versus none with the double C construct. Conclusion: We believe that with proper operative technique and after care, Enders nail may prove to be one of the best implant for paediatric diaphyseal fracture fixation for Indian scenario. The most common complication associated with the procedure are infact features of improper technique and can be eliminated by strictly adhering to the basic principles and technical aspects. While the C and S construct were superior biomechanically, the double C construct is more reliable and straightforward and remains preferred technique.

Fractures of the Capitellum and Trochlea

Recent work has established that apparently isolated fractures of the capitellum are often more complex and involve the lateral epicondyle, trochlea, and posterior aspect of the distal part of the humerus. We assessed the experience with operative stabilization of fractures of the capitellum and trochlea at one level-I trauma center over a twenty-eight-year period. Thirty classifiable partial articular fractures involving the capitellum and trochlea were included in the study. Twenty-seven patients were followed for a minimum of twelve months, and fourteen patients returned for long-term follow-up at a median of seventeen years. The early and long-term results were evaluated according to the Broberg and Morrey Functional Rating Index. The long-term results were also evaluated according to the Mayo Elbow Performance Index (MEPI), the American Shoulder and Elbow Surgeons (ASES) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Eighteen patients (67%) had one or more subsequent surgical procedures, and eight of these patients had the procedure to address surgical complications. Five of the eight patients with complications and ten additional patients underwent routine removal of implants; these fifteen patients included twelve of the fourteen patients in the long-term cohort. In addition to the fracture of the distal part of the humerus, four patients had a dislocation of the elbow; three, a fracture of the olecranon or the proximal part of the ulna; and two, a fracture of the radial head. The median arc of flexion improved from 106 degrees at the time of early follow-up to 119 degrees at the time of long-term follow-up (p < 0.05). In the group of fourteen patients with long-term follow-up, the median Broberg and Morrey score was 93 points at the time of early follow-up and 95 points at the time of late follow-up. The functional results were worse for patients with a Type-3 fracture, as classified with the system of Dubberley et al., than they were for those with a Type-1 fracture. The fourteen patients with long-term follow-up had a median MEPI of 98 points, a median ASES score of 88 points, and a median DASH score of 8 points; nine of the fourteen patients had radiographic signs of arthrosis. The vast majority of what appear to be capitellar fractures are actually complex fractures of the articular surface involving both the capitellum and the trochlea. More complex fractures have worse functional results; however, the functional results of operative treatment seem to be durable over time.

Frakturentherapie bei extremer Adipositas

With the rising prevalence of obesity in the population there will be an increasing need for operative fracture stabilization in obese patients in the future. Orthopaedic surgeons must become familiar with treatment options and also with pre- and postoperative management strategies for such patients: the surgical procedures are technically more challenging, and the rates of infection and implant failure are higher. The implants are too small for morbidly obese patients, in addition to which the surgical approach is made more difficult by the extensive amount of soft tissue. In these patients the treatment of associated pathologic conditions during and after surgery is of vital importance.

Complications of intramedullary Hagie pin fixation for acute midshaft clavicle fractures

The purpose of this report was to evaluate patient outcomes after treatment of acute midshaft clavicle fractures with an intramedullary Hagie pin, including clinical results and the incidence of postoperative complications. Between 1993 and 2003, 16 patients who underwent intramedullary Hagie pin fixation of a midshaft clavicle fracture were identified. The medical records of each patient were reviewed to ascertain the mechanism of injury, indication for surgical intervention, and treatment course. Clinical outcomes were evaluated with respect to time to fracture union, postoperative shoulder range of motion, and symptoms related to the fracture site and ipsilateral shoulder. The inpatient postoperative course and outpatient follow-up visits were assessed in an effort to document the incidence of postoperative complications. The most common mechanism of injury was participation in athletic activity. Operative indications included significant deformity, polytrauma, and neurovascular compromise. The mean time from injury to operative fracture stabilization was 15.8 days. No intraoperative complications occurred. All 16 patients (100%) were available for follow-up to fracture union, which occurred in all cases at a mean of 12.4 weeks. Of the 16 patients, 14 were available for further follow-up, and at a mean follow-up of 9 months, 85.7% had regained near-full to full range of shoulder motion and 93% had no symptoms related to the fracture site or ipsilateral shoulder. Postoperative complications occurred in 8 patients (50%), including 3 cases of skin breakdown related to hardware prominence, 2 cases of hardware breakage, 2 cases of decreased sensation in the region of the surgical incision, and 1 case of persistent pain over the operative site. When indicated, the use of intramedullary devices for the stabilization of clavicle fractures offers theoretic advantages over traditional plate and screw fixation. In this case series, intramedullary Hagie pin fixation resulted in fracture union in 100% of cases, with a high percentage of patients regaining full range of shoulder motion and resolution of symptoms. However, there was a 50% incidence of postoperative complications associated with this treatment method. We believe that the complication rate associated with the use of the Hagie pin should preclude the use of this particular implant.

Risk Factors for Respiratory Failure Following Operative Stabilization of Thoracic and Lumbar Spine Fractures

Respiratory failure is a serious complication that can adversely affect the hospital course and survival of multiply injured patients. Some studies have suggested that delayed surgical stabilization of spine fractures may increase the incidence of respiratory complications. However, the authors of these studies analyzed small sets of patients and did not assess the independent effects of multiple risk factors. A retrospective cohort study was conducted at a regional level-I trauma center to identify risk factors for respiratory failure in patients with surgically treated thoracic and lumbar spine fractures. Demographic, diagnostic, and procedural variables were identified. The incidence of respiratory failure was determined in an adult respiratory distress syndrome registry maintained concurrently at the same institution. Univariate and multivariate analyses were used to determine independent risk factors for respiratory failure. An algorithm was formulated to predict respiratory failure. Respiratory failure developed in 140 of the 1032 patients in the study cohort. Patients with respiratory failure were older; had a higher mean Injury Severity Score (ISS) and Charlson Comorbidity Index Score; had greater incidences of pneumothorax, pulmonary contusion, and thoracic level injury; had a lower mean Glasgow Coma Score (GCS); were more likely to have had a posterior surgical approach; and had a longer mean time from admission to surgical stabilization than the patients without respiratory failure (p < 0.05). Multivariate analysis identified five independent risk factors for respiratory failure: an age of more than thirty-five years, an ISS of > 25 points, a GCS of < or = 12 points, blunt chest injury, and surgical stabilization performed more than two days after admission. An algorithm was created to determine, on the basis of the number of preoperative predictors present, the relative risk of respiratory failure when surgery was delayed for more than two days. Independent risk factors for respiratory failure were identified in an analysis of a large cohort of patients who had undergone operative stabilization of thoracic and lumbar spine fractures. Early operative stabilization of these fractures, the only risk factor that can be controlled by the physician, may decrease the risk of respiratory failure in multiply injured patients.

RISK FACTORS FOR RESPIRATORY FAILURE FOLLOWING OPERATIVE STABILIZATION OF THORACIC AND LUMBAR SPINE FRACTURES

Background: Respiratory failure is a serious complication that can adversely affect the hospital course and survival of multiply injured patients. Some studies have suggested that delayed surgical stabilization of spine fractures may increase the incidence of respiratory complications. However, the authors of these studies analyzed small sets of patients and did not assess the independent effects of multiple risk factors. Methods: A retrospective cohort study was conducted at a regional level-I trauma center to identify risk factors for respiratory failure in patients with surgically treated thoracic and lumbar spine fractures. Demographic, diagnostic, and procedural variables were identified. The incidence of respiratory failure was determined in an adult respiratory distress syndrome registry maintained concurrently at the same institution. Univariate and multivariate analyses were used to determine independent risk factors for respiratory failure. An algorithm was formulated to predict respiratory failure. Results: Respiratory failure developed in 140 of the 1032 patients in the study cohort. Patients with respiratory failure were older; had a higher mean Injury Severity Score (ISS) and Charlson Comorbidity Index Score; had greater incidences of pneumothorax, pulmonary contusion, and thoracic level injury; had a lower mean Glasgow Coma Score (GCS); were more likely to have had a posterior surgical approach; and had a longer mean time from admission to surgical stabilization than the patients without respiratory failure (p < 0.05). Multivariate analysis identified five independent risk factors for respiratory failure: an age of more than thirty-five years, an ISS of >25 points, a GCS of ≤12 points, blunt chest injury, and surgical stabilization performed more than two days after admission. An algorithm was created to determine, on the basis of the number of preoperative predictors present, the relative risk of respiratory failure when surgery was delayed for more than two days. Conclusions: Independent risk factors for respiratory failure were identified in an analysis of a large cohort of patients who had undergone operative stabilization of thoracic and lumbar spine fractures. Early operative stabilization of these fractures, the only risk factor that can be controlled by the physician, may decrease the risk of respiratory failure in multiply injured patients. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Combined Anterior Plus Posterior Stabilization Versus Posterior Short-Segment Instrumentation and Fusion for Mid-Lumbar (L2–L4) Burst Fractures

Prospective randomized study. OBJECTIVES.: To compare the results of the combined anterior-posterior surgery (Group A) with posterior "short-segment" transpedicular fixation (SSTF) (Group B) in mid-lumbar burst fractures. There are no comparative randomized clinical studies on the outcome following operative treatment of mid-lumbar fractures. Forty consecutive patients with L2-L4 fresh single A3-type/AO burst fractures and load sharing score up to 6 were randomly selected to underwent either combined one-stage anterior stabilization with mesh cage and SSTF (Group A) or solely SSTF with intermediate screws in the fractured vertebra (Group B). Kyphotic Gardner angle, anterior and posterior vertebral body height (PVBHr, AVBHr), spinal canal encroachment (SCE), SF-36, VAS, and Frankel classification were used. The follow-up observation averaged 46 and 48 months for Group A and B, respectively. Operative time, blood loss, and hospital stay were significant more in Group A. More surgical complications were observed in the Group A. After surgery, VAS was reduced to 4.3 and 3.6 for Group A and Group B, respectively. The SF-36 domains Role physical and Bodily pain improved significantly only in Group B (P = 0.05) and (P = 0.06), respectively. Correction of AVBHr, PVBHr, and spinal canal clearance was similar in both groups. Spinal canal clearance did not differ between the two groups, but it was continuous until the last evaluation in Group B. The final Gardner angle loss of correction averaged 2 degrees and 5 degrees for Group A and Group B, respectively. The posttraumatic Gardner deformity did not significantly improve by SSTF at the final evaluation in the spines of Group B. Gardner angle correlated significantly with SCE in Group B and Group A in all three periods and in the last evaluation, respectively. Frankel grade did not correlate with loss of correction of AVBHr and PVBHr in Group A, while it significantly correlated with loss of PVBHr correction and SCE in the patients of Group B. There was no neurologic deterioration after surgery in any patient. VAS and SF-36 scores did not significantly correlate with the loss of kyphotic angle correction and AVBHr, PVBHr at the final observation in any patient of both groups. SSTF offered similar significant short-term correction of posttraumatic deformities associated with mid-lumbar A3-burst fractures, but better clinical results as compared to combined surgery. However, SSTF did not significantly maintain the after surgery achieved correction of local posttraumatic kyphosis at the final evaluation. Thus, SSTF is not recommended for operative stabilization of fractures with this severity.

Use of the ring fixator in the treatment of fractures of the lower extremity in long-term paraplegic and tetraplegic patients

Retrospective study. To examine the value of operative fracture stabilization by means of the ring fixator in fractures of the lower extremity in the presence of chronic paralysis caused by transverse lesions of the spinal cord. A specialist center for the treatment of spinal cord injuries in Germany. Clinical examination of the lower extremities with side-for-side comparison, radiological investigation of the fractures, patient survey. In 21 patients with chronic spinal cord lesions, 22 fractures of the lower extremities were treated with the ring fixator. At follow-up a mean of 41.5 months after fracture healing it could be shown that movement in the knee and ankle joints on the same side as the fracture was not restricted by more than 10 degrees in any of our patients. No losses affecting activities of daily living were reported, and 19 of the 21 patients were satisfied with the result achieved with this technique. After four of the 22 operations there were complications. Malalignments were visible radiologically following five of the fractures. In osteoporosis-induced fractures of the lower extremities in chronically paraplegic and tetraplegic patients, fracture stabilization with the ring fixator, with fewer complications and better results in terms of joint mobility, is superior to the conservative treatment so far given preference in the literature. It should be offered as an alternative to conservative treatment in the case of pathological fractures.

Treatment of Fractures Complicated by Burn or Head Injuries in Children*†

The treatment of fractures in children who have multiple injuries is often complex. Fractures that are complicated by burn or head injuries may be especially challenging because such injuries may be extremely severe and the prognosis may be poor. These children may be in extremis or in a very unstable condition at the time of presentation and thus may be poor candidates for anesthesia. Other injuries may be deemed to take precedence, and orthopaedic procedures tend to be postponed. However, because of the unique problems that occur in these patients both immediately after the injury and in the long term, operative stabilization of fractures often can provide great benefits. The coexistence of burn injuries and fractures is not unusual in children because of the association between fire and traumatic injury. Kaplan and Pruitt noted orthopaedic injuries in 197 (6.1 percent) of 3221 patients who had burn injuries11. Because burns and fractures complicate the treatment of each other, there must be some coordination between the trauma surgeon, the general surgeon, or the plastic surgeon who treats burns and the orthopaedic surgeon who treats fractures. ### Initial Evaluation and Resuscitation In the initial management of a patient who has both a burn and a fracture, priority must be given to the airway, breathing, and circulation. Injury to the airway, tissue oxygenation, and replacement of fluids and electrolytes are always concerns in the management of a patient who has a burn. Evaluation of musculoskeletal injury should be deferred until life-threatening conditions are assessed. The history is helpful in guiding the examiner. Children who have been injured in a motor-vehicle accident with a resulting fire and those who have jumped from a burning building are likely to have multiple injuries. The identification of deformity and crepitus is helpful in diagnosing a fracture. Tenderness that is due to …

RAYMOND ROY-CAMILLE, M.D. 1927–1994

RAYMOND ROY-CAMILLE, M.D. 1927–1994

The use of tone-reducing casts to prevent joint contractures following severe closed head injury

The management of patients with concomitant multiple trauma and closed head injury requires specific principles for the treatment of musculoskeletal injuries. Spasticity and agitation complicate closed treatment of fractures, and operative stabilization of fractures is often indicated. Spasticity, impaired cognition, and absence of sensation may prohibit circular cast treatment of extremity injuries in patients with closed head injury. This article presents a case report of a complication following circular cast management to prevent joint contracture in a patient with closed head injury. Circular cast management to prevent joint contractures in patients with closed head injury should be used with extreme caution, especially with concomitant extremity trauma.

ARDS and early fracture fixation : Johnson R. D., Cadambi A. and Seibert G. B. (1985) Incidence of adult respiratory distress syndrome in patients with multiple musculo-skeletal injuries: effect of early operative stabilization of fractures. J. Trauma25, 375

ARDS and early fracture fixation : Johnson R. D., Cadambi A. and Seibert G. B. (1985) Incidence of adult respiratory distress syndrome in patients with multiple musculo-skeletal injuries: effect of early operative stabilization of fractures. J. Trauma25, 375

Incidence of Adult Respiratory Distress Syndrome in Patients with Multiple Musculoskeletal Injuries

Records of 132 consecutive patients with multiple musculoskeletal injuries were examined for the purpose of assessing the relationship between the length of time from injury to the operative stabilization of major fractures and the incidence of adult respiratory distress syndrome (ARDS). To be included in the study patients had to have had at least two major long-bone fractures and a Hospital Trauma Index-Injury Severity Score (ISS) of 18 or higher. Early operative fracture stabilization (STAB) is defined as an operation in the first 24 hours postinjury at which the majority of fractures were stabilized without leaving a spine, pelvis, or femur fracture unstable. A stepwise logistic regression was performed on the data. The dependent variable was the presence or absence of ARDS. The independent variables were age, sex, number of injuries, days to first surgery, early operative fracture stabilization (STAB), units of blood the first week, and ISS and its major components: RESP, ABD, CV, EXT, NS, and SSQ. The two independent variables selected as significant by this procedure were STAB and ISS. For the overall data set, a delay in orthopedic surgery (greater than 24 hours) is associated with a five-fold increase in the incidence of ARDS (p less than 0.001). For the more severely injured patients (ISS greater than 40), the comparable rates are 17% with early surgery and 75% with delayed surgery (p less than 0.001). A Chi-square test for association between ARDS and STAB adjusting for changes due to ISS grouping is significant (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

The injury severity score.

AbstractThe assets and drawbacks of ISS are documented, utilising 2 groups of patients with blunt multiple trauma. Group I consisted of 80 patients with 417 fractures and 163 major associated injuries. Group A had early fracture stabilization and prophylactic ventilation, Group B had early fracture stabilization without prophylactic ventilation, Group C had delayed fracture stabilization and prophylactic ventilatory support. Utilising the ISS, subgroups of A and C were constructed that had injury severity scores ≥ 50 (means 57 and 58.7) containing 19 and 11 patients. Group A had a 10% mortality rate, a late sepsis mortality rate of 6%, and ARDS incidence of 26%, and a mean duration of ventilation of 6 days, while group C had a late sepsis mortality rate of 55%, and ARDS incidence of 82%, and a mean duration of ventilation of 26 days. It is concluded, that early operative stabilization of fractures is safe, and in significant part is associated with a reduced number of late sepsis deaths while reducing the duration of ventilator support required, and that prophylactic ventilator support (i.e., continued support after surgery significantly reduces the incidence of ARDS).Group II consisted of all blunt trauma patients with an ISS greater than 20, admitted during 1981. Sixty‐eight patients were admitted and the correlation was sought between ISS and mortality. It was concluded, that death exclusively from central nervous system injury should be analyzed separately from death from other causes in multiply injured patients. Reference is made to other applications of ISS than the documentation of mortality and suggestions are made for improving ISS by including the Glasgow‐coma scale and including patients related risk data. A plea is made to devise a standard method for ISS calculation.

Physiological Fixation of Displaced and Unstable Fractures of the Hand

The operative stabilization of fractures of the hand should not be considered a "radical" approach to the treatment of these injuries. These methods, when properly applied and well executed, influence wound healing by restoring the original length and alignment of the injured tissues. Skeletal stability allows immediate joint mobility in a protected environment. A rapid return to a state of tissue equilibrium can be predicted in many cases.

Operative stabilization of fractures of the humeral shaft with Hackethal bundle nails

Operative stabilization of fractures of the humeral shaft with Hackethal bundle nails