Severity Of Soft Tissue Injury Research Articles

OPEN FRACTURE MANAGEMENT: UPDATE ON INITIAL EVALUATION AND CLASSIFICATION

This article reviews the management of open fractures, which occur when there is a break in the skin exposing the underlying bone and soft tissues, leading to signicant morbidity and mortality. The article focuses on the initial evaluation, classication, and treatment of these fractures. The Gustilo-Anderson classication system, which is based on the degree of soft tissue injury, is the most widely used classication system for open fractures. However, the Tscherne classication system, which focuses on the severity of soft tissue injury and the degree of fracture displacement, has been shown to be a more reliable predictor of infection and nonunion in some studies. The article also covers the AO/OTA classication system, a newer classication system that integrates important aspects of the Gustilo-Anderson classication system to provide more comprehensive guidance for the treatment of open fractures. Treatment of open fractures is complex and requires a multidisciplinary approach guided by the severity of the injury. Early antibiotics, early surgical debridement, and wound irrigation have been shown to reduce the risk of infection and improve outcomes. Patients with open fractures were more likely to have associated injuries, longer hospital stays, and higher hospital costs compared to patients with closed fractures

Assessing Soft Tissue Perfusion Using Laser-Assisted Angiography in Tibial Plateau and Pilon Fractures: A Pilot Study.

To determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. Prospective cohort study. Academic trauma center. Eight pilon fracture patients and 19 tibial plateau fracture patients who underwent open reduction internal fixation. Skin perfusion (fluorescence units) as measured by LA-ICGA. Six patients were classified as Tscherne grade 0, 9 as grade 1, 10 as grade 2, and 2 as grade 3. Perfusion decreased by 14 fluorescence units (95% confidence interval, -21 to -6; P < 0.01) with each increase in Tscherne grade. Sixteen patients underwent staged fixation with an external fixator (mean time to definitive fixation 14.1 days). The mean perfusion increased significantly at the time of definitive fixation by a mean of 13.9 fluorescence units (95% confidence interval 4.8-22.9; P = 0.01). LA-ICGA perfusion measures are associated with severity of soft tissue injury surrounding orthopaedic trauma fractures and appear to improve over time when fractures are stabilized in an external fixator. Further research is warranted to investigate whether objective perfusion measures are predictive of postoperative wound healing complications and whether this tool can be used to effectively guide timing of safe surgical fixation. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Bioinformatic analysis and experimental identification of blood biomarkers for chronic nonunion

BackgroundIncomplete fracture healing may lead to chronic nonunion; thus, determining fracture healing is the primary issue in the clinical treatment. However, there are no validated early diagnostic biomarkers for assessing chronic nonunion. In this study, bioinformatics analysis combined with an experimental verification strategy was used to identify blood biomarkers for chronic nonunion.MethodsFirst, differentially expressed genes in chronic nonunion were identified by microarray data analysis. Second, Dipsaci Radix (DR), a traditional Chinese medicine for fracture treatment, was used to screen the drug target genes. Third, the drug-disease network was determined, and biomarker genes were obtained. Finally, the potential blood biomarkers were verified by ELISA and qPCR methods.ResultsFifty-five patients with open long bone fractures (39 healed and 16 nonunion) were enrolled in this study, and urgent surgical debridement and the severity of soft tissue injury had a significant effect on the prognosis of fracture. After the systems pharmacology analysis, six genes, including QPCT, CA1, LDHB, MMP9, UGCG, and HCAR2, were chosen for experimental validation. We found that all six genes in peripheral blood mononuclear cells (PBMCs) and serum were differentially expressed after injury, and five genes (QPCT, CA1, MMP9, UGCG, and HCAR2) were significantly lower in nonunion patients. Further, CA1, MMP9, and QPCT were markedly increased after DR treatment.ConclusionCA1, MMP9, and QPCT are biomarkers of nonunion patients and DR treatment targets. However, HCAR2 and UGCG are biomarkers of nonunion patients but not DR treatment targets. Therefore, our findings may provide valuable information for nonunion diagnosis and DR treatment.Trial registrationISRCTN, ISRCTN13271153. Registered 05 April 2020—Retrospectively registered.

To evaluate the functional and radiological outcome of compound tibia shaft fracture treated with primary interlocking nail

Introduction: The Tibial shaft fracture are most common seen in road traffic accidents, Degree of displacement of fractures, degree of comminution, signs of infection and severity of soft tissue injury are the most important prognosis factors. Nail is a load sharing device with stiffness in both torsional and axial forces. Least damage to soft tissues is done by closed interlocking nailing. Aim: To evaluate the functional and radiological outcome of Compound Tibia shaft fracture treated with primary interlocking nail. Method: The present study was conducted in the department of Orthopaedics of SRMS-IMS, Bareilly from 2017-2020 on 20 patients, Extra articular Open tibia fractures with/without fibula fracture, Age above 18 years, Grade I, II & IIIA (Gustilo Anderson’s classification). Exclusion criteria: Open Tibial fracture treated primarily with external fixation, Non union of tibial fractures, Intra-articular fractures, Closed tibial fractures, Grade IIIB & IIIC fractures (Gustilo Anderson’s classification). standard surgical procedure of intramedullary interlock nailing of tibia was done. regular follow up was done with clinical and radiological assessment and final results made using Modified Ketenjian and Shelton Criteria. Result: 85% of the cases were male, with 55% grade 1, 40% grade 2 and 5% grade 3A. 60% cases were due to RTA. 55% of cases had middle third fracture tibia,70% of cases were operated within 48 hours, the mean union time was 20 weeks by then full weight bearing walker walking was started. 20% of patient showed superficial infection which got resolved by regular dressing, with 1 case of delayed union and 2 cases of stiffness. at the end of 6 months 70% showed excellent, 25% good and 5% satisfactory results. Conclusion: The fractures in our study united in an average of about 20 weeks. This one time procedure of Interlocked intramedullary nailing done which lead to union in almost all the cases. This procedure allows earlier fracture union hence early weight-bearing. Because of the high union rate and low infection rate, we consider closed interlocking nailing as the best mode of treatment for compound diaphyseal tibial fractures upto Gustilo-Anderson grade 3A.

Correlation Between Soft Tissue Injury and the Type of Nasal Fracture Based on Stranc-Robertson Classification.

Nasal fractures are the most common facial bone fractures, and soft tissue injuries are frequently accompanied. This study intends to make a deep analysis on the relationship between the 2.Patients diagnosed with nasal fracture between 2015 and 2017 were included. Patients younger than 17 years and those with previous facial fractures or aesthetic surgeries were excluded. Nasal fractures were classified according to the Stranc-Robertson (S-R) classification, and the severity of soft tissue injury was evaluated by length and depth. The authors compared the frequency of soft tissue injury between frontal and lateral groups. Second, the authors investigated whether the incidence of soft tissue injuries increases as a function of the increase in the S-R classification both in frontal and lateral group (from plane I to III). The authors also analyzed the difference in severity of soft tissue injuries in each group. Pearson chi-square analysis, linear by linear and Jonckheere-Terpstra tests were used for statistical analysis.Of 621 patients, 296 were frontal plane and 325 were lateral plane. The frontal group had a higher incidence of soft tissue injury than the lateral group (P = 0.004). The incidence of soft tissue injury and severity by depth increased as a function of the increase in the S-R classification only in the frontal group (P = 0.046, 0.019).In nasal fractures, frontal impact is more associated with frequency and severity of soft tissue injury than lateral impact. This seems to be related to the anatomical characteristics of nasal area and mechanism of injuries in each group.

Tibial Fracture Nonunion and Time to Healing After Reamed Intramedullary Nailing: Risk Factors Based on a Single-Center Review of 1003 Patients.

To determine factors associated with nonunion of adult tibial fractures. Retrospective review with data collection for logistic regression and survival analysis. Scottish Level I trauma center, 1985-2007. During this period, 1590 adult tibial fractures were treated by reamed nailing and 1003 fractures met all inclusion criteria for the chosen analysis. Reamed intramedullary nailing. Record of nonunion diagnosis and final union time with characteristics, including age, gender, closed or open injury, OTA/AO classification, Gustilo classification, fasciotomy, infection, polytrauma, smoking, and injury severity score. The overall nonunion rate was 12%, and median time to healing was 18 weeks. Age significantly influenced nonunion, with middle-aged patients at highest risk. Both fracture type (closed/open) and morphology (OTA/AO classification) significantly influenced nonunion risk and time to union. Among closed injuries, the highest nonunion rate was for OTA/AO type B fractures (15%). Among open injuries, the highest nonunion rate was for OTA/AO type C (61%). Both compartment syndrome and smoking did not significantly influence nonunion risk but did significantly extend time to union. Injury characteristics including fracture morphology and severity of soft tissue injury were strong predictors of compromised fracture healing. Age also influenced nonunion risk in an unexpected way, with highest rates in the middle decades of adulthood. Future studies should consider the possibility of similar age-related effects and clinical studies should seek to identify explanations for why this may arise, including both physiological and socio-behavioral factors. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Functional outcomes and complications of open elbow dislocations.

BackgroundThe current study investigated the clinical outcome of open elbow dislocations, focusing on the influence of associated soft tissue and bone injury.Patients and methodsFrom October 2008 to August 2015, 230 patients with elbow dislocations were treated at the study center. Our retrospective study comprised 21 cases of open elbow dislocations. The mean age of patients was 49 years (20–83 years); there were six (29%) female and 15 (71%) male patients. The range of motion (ROM) of the injured and uninjured elbow was measured, and the Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS), and Disability of Arm, Shoulder and Hand (DASH) score were assessed. Complications and revision surgeries were recorded. The influence of the severity of soft tissue injury (I°/II° open vs. III° open) and type of dislocation (simple vs. complex) was evaluated.ResultsAfter a 57-month follow-up (range, 24–98 months), the mean DASH score was 20 ± 15, the MEPS was 82 ± 11, and the MWS was 74 ± 22. The ROM of the injured elbow was significantly decreased compared with the uninjured one (arc of ulnohumeral motion: 104° vs. 137°; p = 0.001). Patients with I°/II° open elbow dislocations had a better clinical outcome according to the MEPS (86 ± 11 vs. 76 ± 9; p = 0.045) and a comparable outcome according to the DASH score (19 ± 18 vs. 21 ± 9; p = 0.238). In all, 11 patients (52%) had postoperative complications and 11 patients underwent at least one revision surgery. Complex elbow dislocations had significantly more complications and revision surgeries than simple dislocations (77% vs. 13%; p = 0.008).ConclusionFavorable clinical outcomes can be achieved after treatment of open elbow dislocations. These injuries are prone to neurovascular damage and complex dislocations are linked to high rates of complications and revision surgeries.

Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications.

Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications. A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA). Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed. Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.

A prospective study of locking plate fixation in tibial plateau fractures

Introduction: Originally described as the fender fracture tibial plateau fractures resulted primarily from low-energy pedestrian versus car bumper accidents. The majority of tibial plateau fractures reported in the recent literature have resulted from high-speed motor vehicle accidents and falls from a height. Injuries to the tibial plateau occur as a result of a force directed either medially (valgus deformity, the classic “bumper fracture”) or laterally (varus deformity), an axial compressive force or both an axial force and a force from the side. Locking Compression plates have become and imminent tool in the management of these complex fractures. Aim: The aim of the study is to analyze prospectively by clinical, radiological and functional methods the results of open/closed reduction and internal fixation of closed tibial plateau fractures treated by Locking Compression Plates. Method: This is a prospective study conducted in Chengalpattu Medical College and Hospital, Chengalpattu. Twenty patients who satisfied the following criteria were included in our study. Depending on the type of fracture and severity of soft tissue injury all the patients were stabilized initially and closed or open reduction of the fracture done and fracture stabilized with locking compression plate. Discussion and Conclusion: The results were analyzed both clinically and radiologically using the Knee scoring system by Hospital for Special Surgery. Results based on Knee Scoring System, Hospital for Special Surgery (HSS) we had excellent result in 10 cases, good result in 7 cases, fair result in 3 cases and we had no poor result. From our study, we conclude that, Open/closed reduction and internal fixation of closed tibial plateau fractures with locking compression plate is an effective method of treatment provided there is no extensive soft tissue injury. Locking compression plate provides good angular stability with its triangular reconstruction principle.

Severity of Soft Tissue Injury Within the Temporomandibular Joint Following Condylar Fracture as Seen on Magnetic Resonance Imaging and Its Impact on Outcome of Functional Management

This study aimed to quantify articular soft tissue injury in condylar fractures based on magnetic resonance imaging (MRI) findings and investigate the impact of severity of articular soft tissue injury on the development of postoperative complications after functional reduction of a condylar fracture. Fifty-four patients 18 to 60 years old with unilateral undisplaced, deviated, or displaced condylar fractures were included in this prospective study. Articular soft tissue within the temporomandibular joint (TMJ) was evaluated using MRI within 7 days after the condylar fracture. Based on MRI findings, such injuries were classified as grade I (hemarthrosis only), grade II (hemarthrosis and disc displacement), grade III (hemarthrosis, disc displacement, and capsular tear), or grade IV (disc perforation in association with grade I, II, or III). All condylar fractures were treated conservatively using a standardized functional reduction method and patients were followed for 1 year. In 37 of 54 TMJs, MRI diagnosis of disc displacement was established, and capsular tear was observed in 12 joints and hemarthrosis was present in 42 joints. Disc perforation was present in only 5 cases. Patients with hemarthrosis alone (grade I) had the best outcome after functional reduction, whereas patients with hemarthrosis and disc displacement (grade II) had comparatively poorer results. Fifty percent of patients with grade II injury and 66.6% of patients with associated capsular tear (grade III) had limited mouth opening and restricted movement at the end of the follow-up period. One hundred percent of patients with disc perforation (grade IV) had restricted joint movement and joint noise. Results suggest that serious injury to the articular disc and capsule of the TMJ is a major contributing factor toward the development of complications after closed reduction of a condylar fracture.

Intra- and interobserver agreement on the Oestern and Tscherne classification of soft tissue injury in periarticular lower-limb closed fractures

The soft tissues injury in periarticular fractures of the lower extremities determines the proper time to perform bone fixation. The aim of this study was to determine the intra and interobserver agreement in the Tscherne classification. This is a descriptive, prospective study for patients admitted to the Pablo Tobón Uribe Hospital (PTUH) with tibial plateau or tibial pilon fractures. We performed a standardize evaluation using video photography at the time of admission and 24, 48, and 72 h after admission. Fifteen five reviewers who had various levels of training produced a total of 1,200 observations. The intra- and interobserver agreement was assessed using a weighted kappa for multiple raters and more than two categories. Twenty patients were admitted with tibial plateau and tibial pilon fractures. The intraobserver agreement for all 15 raters was kappa 0.81 (95% CI 0.79-0.83), and the interobserver agreement for all 15 raters was kappa 0.65 (95% CI 0.55-0.73). The interobserver agreement at 24 h was kappa 0.67 (95% CI 0.46-0.86). Classifying the severity of soft tissue injury is critical in planning the surgical management of fractures of the lower extremities. Based on our results, we can reasonably argue that the Tscherne classification produced an adequate level of agreement and could be used to standardize and to guide the treatment, and to conduct research studies.

Delayed union and nonunions: Epidemiology, clinical issues, and financial aspects

Fracture healing is a critically important clinical event for fracture patients and for clinicians who take care of them. The clinical evaluation of fracture healing is based on both radiographic findings and clinical findings. Risk factors for delayed union and nonunion include patient dependent factors such as advanced age, medical comorbidities, smoking, non-steroidal anti-inflammatory use, various genetic disorders, metabolic disease and nutritional deficiency. Patient independent factors include fracture pattern, location, and displacement, severity of soft tissue injury, degree of bone loss, quality of surgical treatment and presence of infection. Established nonunions can be characterised in terms of biologic capacity, deformity, presence or absence of infection, and host status. Hypertrophic, oligotrophic and atrophic radiographic appearances allow the clinician to make inferences about the degree of fracture stability and the biologic viability of the fracture fragments while developing a treatment plan. Non-unions are difficult to treat and have a high financial impact. Indirect costs, such as productivity losses, are the key driver for the overall costs in fracture and non-union patients. Therefore, all strategies that help to reduce healing time with faster resumption of work and activities not only improve medical outcome for the patient, they also help reduce the financial burden in fracture and non-union patients.

Analysis of Clinical Outcome and Prognosis for Lisfranc Joint Fracture and Dislocation according to the Injury Mechanism and Treatment Method

Purpose: The purpose of this study was to assess the treatment outcomes and prognosis of Lisfranc joint fracture and dislocation according to the mechanism of injury and treatment method. Materials and Methods: Twenty six patients with Lisfranc fracture-dislocation who had been treated surgically were included in this retrospective study. The patients were divided into two groups according to mechanism of injury: direct crushing injury (16 patients) and indirect rotational or compressive injury (10 patients). The patients were also divided into three groups according to the surgical methods. The parameters used were radiographic evaluation, patients’ subjective satisfaction levels, length of hospital stay, and the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score. Statistical analysis was performed. Results: The mean postoperative AOFAS midfoot score was 78.7. The mean length of stay was 39.6 days. Statistically significant differences in subjective satisfaction, AOFAS midfoot score, and length of hospital stay were observed between the two groups (p 0.05). Conclusion: Mechanism of trauma and the severity of soft-tissue injury were significant prognostic factors affecting the surgical outcomes of Lisfranc joint fracture and dislocation.

The effect of the Tscherne injury pattern on the outcome of operatively treated Lisfranc fracture dislocations

Lisfranc fracture dislocations cause severe tarso-metatarsal malalignment. The research question of this study was to evaluate the severity of the soft tissue injury on the final clinical outcome and compare that with the effect of various determinants on the disability in daily living activities after open reduction and internal fixation of a Lisfranc injury. This study consisted of a retrospective analysis of patients with Lisfranc fracture dislocations who were treated by open reduction and internal fixation beween 2004 and 2009. Evaluation focused mainly on the severity of the soft tissue injury, age, fracture classification, time to operation, posttraumatic osteoarthritis, and the results were compared with American Foot and Ankle Society (AOFAS) scores, and Foot and Ankle Disability Index (FADI). Eight patients had Tscherne Grade 1, 13 had Grade 2, and 11 had Grade 3 soft tissue injuries. Myerson classification revealed 11 type A, 8 type B and 13 type C fractures. Six patients' operations were delayed beyond 8h. Of the 38 patients treated in the study period, 32 patients (11 female, 21 male; <30 y-old: 14, >30 y-old: 18) were available for complete follow-up (average, 55.5 months). The comparison of treatment results revealed that those patients with high grade soft tissue injuries had lower AOFAS and FADI scores (43.8±15.9, 53.7±9.4, respectively) when compared to Tscherne Grade 1 injuries (82.8±6.1, 109±13.9, respectively) (p<0.001). The overall negative impact of the severity of soft tissue injury on functional outcomes had similar significance with regard to post-traumatic osteoarthritis, and fracture type. There was also a statistically significant difference between outcome measures and post-reduction quality (p=0.002). Patient age (p=0.9) and delayed surgery (p=0.5) had no statistically significant effect on the final outcome. Satisfactory results can be achieved with open reduction for Lisfranc injuries. However, despite this treatment, both the severity of the soft tissue injury and non-anatomic reduction are negative prognostic factors in the treatment of Lisfranc fracture dislocations.

Case Scenario: Compartment Syndrome of the Forearm in Patient with an Infraclavicular Catheter

Case Scenario: Compartment Syndrome of the Forearm in Patient with an Infraclavicular Catheter

Tibial fracture treated by minimally invasive plating using a novel low-cost, high-technique system

The less invasive stabilization system (LISS) can effectively treat tibial fractures. However, the LISS is technically demanding, has a long learning curve, and presents a heavy economic burden to patients. The U-grooved locking compression plate (U-LCP), characterized by a U-groove at each end, is designed to treat tibial fractures. This paper reports the outcomes of tibial fractures treated using the U-LCP compared with the LISS. Seventy-eight patients with unilateral tibial fractures treated with either the U-LCP (group I) or LISS (group II) were enrolled. In group I, a U-LCP was inserted subcutaneously with two Kirschner wires embedded into the U-grooves to temporarily secure the plate. A second identical plate was placed over the first to guide screw insertion. In group II, the LISS was used to fix the tibial fractures. Patient age, sex, fracture type, severity of soft tissue injury, operative time, fluoroscopic time, complications, and functional recovery of affected limbs were recorded. The two groups were comparable in age, sex, fracture type, and severity of soft tissue injury (p > 0.05). The average operation and fluoroscopic times in group I were significantly less than those in group II (p < 0.05). At follow-up, all fractures healed. There were no significant differences between both groups in time to bony union, wound complication rate, or functional recovery of injured limbs (p > 0.05). The U-LCP can yield good outcomes in the treatment of proximal tibial fractures, with less radiation exposure, a shorter operation time, and a sustainable price compared with the LISS.

Floating knee: epidemiology and results of treatment

Introduction: Floating Knee is the term applied to ipsilateral fractures of the femur and tibia. Management of this complex injury has been variously described in the literature. This retrospective study was designed to present our experience with treatment of this injury, its complications and the functional results of these patients. Material and Methods: Between January 2004 and December 2007, all floating knee injuries that were managed during the study period were included. The patients were divided according to Fraser's classification. Functional assessment and final outcome was measured using the Karlstrom and Olerud's criteria. Results: Our study included 43 patients with 43 floating knee injuries. There were 32 males and 11 females with a mean age of 37 years. All patients had sustained their injuries in motor vehicle accidents. Thirty nine associated injuries were noted in the 43 patients. According to Fraser's classification, there were 21 type I, 10 type IIa, 7 type IIb, and 5 type IIc. Most of the floating knee injuries were treated with antegrade intramedullary nailing for both the femur and tibia. The mean follow up was 24.8 months. All the fractures united within a reasonable time except for three femur and 14 tibias. The complications encountered were one case of fat embolism, eight case of knee stiffness, 10 cases of delayed union, nine cases of infections, and seven cases of nonunion. Assessment by the Karlstrom criteria revealed 12 excellent results, 19 good results, 4 acceptable results, and 8 poor results. Analysis showed that surgical results were significantly associated with Fraser type classification of floating knee injuries (p = 0.003), the severity of soft tissue injury in the leg (grade III opened fracture) (p = 0.008), and associate lesions (p = 0.001). Conclusion: In patients suffering from floating knees, early fixation is recommended since it has several advantages with few systemic complications. We found Floating knee injuries to be a group of complex injuries that needed careful assessment to detect poor prognostic factors. Combination of all these would determine the ultimate outcome of these patients. Key words: Floating knee, Intramedullary fixation, Associate lesions, Surgical treatment.

Bicycle-Spoke Injuries of the Foot in Children

To evaluate the characteristics of bicyclespoke injuries in a suburban Indian population. 30 male and 11 female children aged 4 to 12 (mean, 6) years with bicycle-spoke injuries were prospectively studied. Data collected included patient age, gender, position at the time of injury, site, type, and characteristics of the injury. According to the Oestern and Tscherne classification, soft-tissue injuries were classified into grades 0 to 3. 37 patients injured the right foot, and 4 the left foot; 34 by the rear wheel and 7 by the front wheel. All front-wheel injuries involved the forefoot and midfoot. 73% of injuries involved the lateral aspect of the ankle. The most common injury site was the posterior ankle (n = 30), followed by the medial midfoot (n = 7), and the forefoot (n = 3). Partial avulsion of heel flap and an exposed Achilles tendon were each noted in 2 patients. 10, 13, 14, and 4 patients sustained soft-tissue injuries of grades 0, 1, 2, and 3, respectively. Eight patients had associated fractures. All fractures healed uneventfully. Marginal necrosis of the wound was noted in 5 patients, but none required a skin graft. No patient had functional impairment or residual tenderness of the foot. Bicycle-spoke injuries usually affected the ankle region, and the wound was usually deeper than it appeared on initial examination. Reassessment of the wound after 48 hours is recommended. Severity of soft-tissue injury was the determinant of overall function; bone fractures by themselves did not alter the duration of recovery. To prevent bicyclespoke injuries, spoke guards and foot rests should be used, and children being carried on a bicycle should wear proper shoes. Education on injury mechanism, severity, and preventive measures is also important.

Proximal Tibial Metaphyseal Fractures with Severe Soft Tissue Injury: Clinical and Functional Results at 2 Years

Controversy exists regarding management of proximal tibial metaphyseal fractures with severe soft tissue injury. It is unclear whether limb salvage or early amputation results in the best functional and clinical outcomes. We hypothesized that in this group of patients, there is no difference in functional outcomes, complication rates, clinical outcomes, or objective physical function related to the treatment approach. We used the LEAP study database to perform a retrospective comparative review of a subset of patients with proximal tibial metaphyseal fractures (AO/OTA 41A, B, and C) with associated severe soft tissue injuries comparing the outcomes of patients who were treated with either limb salvage or amputation. Although there were major differences in clinical and functional outcomes based on patients' sociodemographics at 2 years, no differences in clinical or functional outcomes were detected regardless of whether amputation or limb salvage was performed. Severity of soft tissue injury was more predictive of outcome than the surgical approach used. Sociodemographics and soft tissue injury severity are more important than treatment approach for predicting clinical and functional outcomes at 2 years in patients with proximal tibia metaphyseal fractures with severe soft tissue injury. Level III, retrospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.

Percutaneous Contoured Locking Plate Fixation of the Pilon Fracture: Surgical Technique

Preservation of the soft tissue is of particular importance in the care of pilon fractures. Improper soft tissue management has been attributed to high rates of nonunion, nerve injury, and failures (1–12). Traditional open reduction internal fixation (ORIF) of pilon fractures allows for direct visualization of the fracture(s) but is criticized for the large exposure and periosteal stripping. As a result, this approach has been blamed for high nonunion rates as well as failure of the soft tissue to accommodate implants (1, 5, 8, 13). External fixation has also been used but has not demonstrated much advantage to internal fixation and requires significant postoperative care. Also, external fixation has a higher incidence of malunion (6, 14) and has inherent risks for pin-tract infections (14, 15). In an attempt to limit the iatrogenic soft tissue injury (5, 6, 7), some surgeons have used a limited ORIF concentrating on restoration of the articular surface combined with ring or hybrid external fixation. The “2-stage” technique combines the benefits of both external and internal fixation, and is thought to limit soft tissue related complications by allowing soft tissue recovery time before the introduction of internal fixation. Initial temporary external fixation combined with limited exposures for internal fixation (2-stage technique) at a later date allows for less disruption of the soft tissue envelope, leading to a decrease in complications associated with traditional open approaches. This may be achieved through relatively “small incisions” extending from the pole of the malleolus to the metaphyseal fracture(s), although these incisions can still be quite long, especially when significant articular reconstruction and/or bone grafting is required. Other descriptions include “limited approach” or “minimally invasive”; and this differs from a true percutaneous approach. With the advent of locking plate technology, surgeons have successfully managed a variety of fractures though smaller incisions to introduce the plate(s)—the percutaneous approach. Unlike traditional plating methods, locking plates do not rely on frictional forces between the plate/bone interface to achieve compression and stability. This allows for less damage to the periosteal blood supply, which may theoretically decrease the incidence of delayed or nonunion, soft tissue complications, and possibly secondary loss of fixation (16, 17). A recent study by Salton et al (18) demonstrated no major complications and only 4 minor soft tissue complications in a series of 19 patients treated with a limited incision and percutaneous medial plate fixation. More recently available contoured locking plates with multiple options for metaphyseal screw placement through the “percutaneous” incision allow for the surgeon to achieve stability through this access point. With percutaneous locking plates, the incision may be even smaller than used with the traditional 2-stage technique.