Early fracture fixation in the multiply injured patient has been shown to reduce morbidity and mortality. This premise recently has been questioned when the multiply injured patient has a pulmonary contusion, and also has a femoral fracture stabilized with a reamed intramedullary nail. This put into question whether early stabilization of femoral fractures, especially with a reamed intramedullary nail, should be performed in patients with a pulmonary contusion. A review of the most recent clinical and animal research was performed to help answer this question. This review has revealed that the incidence of pulmonary failure and adult respiratory distress syndrome in multiply injured patients with thoracic injuries who have femoral fractures treated acutely is less than 3%. The morbidity associated with patients with pulmonary contusions is independent of the treatment of the femoral fracture. No difference in the rate of pulmonary failure is found with reamed nails or plate fixation. The pulmonary failure seems to be secondary to the pulmonary contusion, not to the method of fracture fixation.

A study of ninety-nine patients who had a unilateral, displaced, isolated closed fracture of the tibial shaft was performed to determine the effect of the type of treatment on the clinical outcome. Forty-seven patients were managed with closed intramedullary nailing with reaming, and fifty-two were managed with closed reduction and a cast. The two groups were comparable with regard to the ages of the patients, the locations and amounts of displacement of the fractures, and the number of patients who had a history of smoking. The time to union was shorter in the patients who had been managed with intramedullary nailing than in those who had been managed with a cast (mean, eighteen compared with twenty-six weeks; p = 0.02). A non-union occurred in one patient (2 per cent) who had been managed with nailing and in five patients (10 per cent) who had been managed with a cast. There were no infections in either group. Removal of the nail was performed electively in twenty-six patients.Twenty-five patients who had been managed with nailing and twenty-five who had been managed with a cast were followed for a mean of 4.4 years. With use of the Iowa Knee Evaluation and the Ankle-Evaluation Rating System, the patients who had had nailing had mean scores of 96 points (range, 68 to 100 points) and 97 points (range, 74 to 100 points) for the knee and the ankle, respectively, compared with 89 points (range, 62 to 100 points) and 84 points (range, 62 to 100 points) for those who had been managed with a cast (p < 0.05). Administration of the Medical Outcomes Study Short Form-36 Health Survey to the twenty-five matched pairs of patients yielded scores that were significantly better after nailing than after treatment with a cast (a mean of 85 points [range, 27 to 99 points] compared with a mean of 74 points [range, 20 to 97 points]; p < 0.05).We concluded that the treatment of displaced closed fractures of the tibial shaft with closed intramedullary nailing with reaming provides functional results that are superior to those obtained with use of a cast.

It has been well documented that early fracture stabilization reduces morbidity and mortality in the patient who is multiply injured. However, controversy has developed recently concerning the timing and type of stabilization for the patient with multiple injuries who has sustained a femoral fracture and an associated severe chest injury. Reports from Europe have indicated an increased mortality rate and adult respiratory distress syndrome rate in the patient treated with reamed femoral rodding. A retrospective review of patients with multiple injuries with Injury Severity Scores of 18 points or greater who also had severe chest trauma was done at the Erie County Medical Center, Buffalo, NY. Three groups of patients were developed and studied: The patients in Group 1 had femoral fractures that were treated with early stabilization with a reamed rod; the patients in Group 2 had femoral fractures stabilized with plate fixation; and in Group 3, there were no femoral fractures. The Injury Severity Score for each group was nearly the same; however, the intensive care unit time was more than doubled in Group 2 and Group 3. There was a 33% adult respiratory distress syndrome rate in Group 2, a 27% rate in Group 3, and a 0% rate in Group 1. The mortality rate was highest for the group of patients without femoral fractures (Group 3), 10.9%. These clinical data seem to associate the chest injury with the increased adult respiratory distress syndrome and mortality rate, not the method of treatment for the femoral fracture.

This study was designed to verify whether open tibial fractures treated with an unreamed tibial nail would heal without the placement of a bone graft. Twenty-nine consecutive patients treated with unreamed tibial nails were prospectively followed to study fracture healing patterns. Monthly radiographs were studied for signs of healing without additional surgical intervention until it appeared that the fracture was a delayed union or nonunion. The average patient age was 31 years (range 16-80). Twenty-seven of the fractures were open (16 grade I, 8 grade II, 3 grade IIIA), with two additional fractures with compartment syndrome open by surgical intent. All fractures resulted from high-energy trauma. Twenty-two fractures were comminuted or segmental. Fifteen fractures healed without secondary intervention at an average of 148 days (range 98-243). Fourteen fractures needed additional intervention from between 3 and 7 months postinjury, with an average intervention of 1.9 per fracture. The two groups (primary healing and delayed union) were similar in fracture location, mechanism, and grade of injury. However, 13 of 14 delayed unions had comminuted or segmental fractures and required statically locked nails in 13 of the 14 fractures. Our experience suggests that the union rate is not improved with unreamed nails over that in the historical external fixator literature unless secondary surgical procedures are performed to change the local biology and enhance healing. We suggest early nail dynamization and bone grafting at 6 weeks to enhance and shorten healing time.

A multicentered study was performed to determine the mortality rate of patients with multiple injuries with major pelvic and long bone fractures who have early total care of their injuries. A 2-year review of patients with ISSs > or = 18 with major fractures treated at the trauma centers in Buffalo, New York, Camden, New Jersey, Nashville, Tennessee, Baltimore, Maryland, Tampa, Florida, and Seattle, Washington was performed. This group of 676 patients was compared with a similar group of 906 patients from the American College of Surgeons' Multiple Trauma Outcome Study. Mortality was significantly reduced in the patients who had early total care of all their injuries including fracture stabilization for patients less than 50 years of age and those 50 years and older. In a subgroup of patients less than 50 years of age and an ISS of 18-34 and 35-45 there was a mortality reduction from 11.8% to 5.1% and from 25.8% to 11.5%, respectively, when the fractures were managed acutely. Similar reductions in mortality were found in the patients 50 years of age and older with early fracture stabilization with a reduction from 26.4% to 8% in patients with ISSs of 18-24 and a reduction from 42.3% to 18.4% in the patients with ISSs of 35-45. This study clearly shows the additional benefit of early fracture stabilization in reducing mortality rates in the patient with multiple injuries.

A prospective randomized study of severe open tibial fractures (Type II and III) was performed. Individual fractures were randomized to treatment groups according to initial antibiotic therapy: One consisted of a first-generation cephalosporin, and the other consisted of a third-generation cephalosporin. Initial antibiotic therapy was given in all patients for 48 h and then specific antibiotic treatment was used as indicated by culture. The purpose of this study was to determine whether or not additional gram-negative coverage had an effect on the overall infection rate or the type of infection in severe open tibial fractures. Additional factors, such as the timing of bone grafts and soft tissue coverage, were evaluated in this study as well. Although there was no statistical difference in the rate of infection with the use of a first- versus a third-generation cephalosporin, there was a trend toward a decreased infection rate as well as toward less morbid infections with the use of a third-generation cephalosporin. The study also confirms that early bone graft should not be performed prior to 6 weeks post injury or after successful soft tissue coverage has been achieved. On the other hand, soft tissue coverage procedures should be performed at the earliest possible date to decrease the overall infection rate.

Clinically, implant failure is often the result of fatigue from continuous cyclic loading. Because of the inadequacies of long-run cyclic testing, fatigue susceptibility of implants was investigated by means of strain measurements and stress analysis under physiologic loads. The implants were equipped with strain gauges during load-deformation testing, and the tensile stress (the component of stress-producing fatigue failure in metals) was calculated for that site on the implant. For metals most often implanted for spinal surgery, such as stainless steel and chrome-cobalt alloys, a stress exists, known as the endurance limit, below which failure will not occur, even if cycled indefinitely. By calculating the tensile stresses in an implant and relating them to the endurance limit, the implant's susceptibility to fatigue can be determined at the site of stress analysis without formal cyclic load testing.

This study demonstrates that the broad 4.5 mm dynamic compression plate provides superior stiffness in axial and torsional loading compared to the two anterior rod constructs (Zielke-Slot and Kostuik-Harrington) and the thinner ASIF T-plate in this ex-vivo testing. The Armstrong National Research Council (NRC) plate, designed specifically for anterior spinal instrumentation, has essentially the same mechanical performance characteristics as the broad dynamic compression plate. When placed on the lateral aspect of the vertebral body, these latter two plates lie well away from the anterior vascular structures. Screws are placed slightly off set in the plate, two each in the vertebral bodies immediately above and below the fracture, the screws directed transversely across the vertebral body. The broad DCP plate is easily contoured and implanted, and will allow 1.8 mm of compression to be applied to a strut graft between vertebral bodies. Anterior surgery for the treatment of burst fractures with retropulsed bone provides a means for direct decompression of the spinal canal. With an appropriate implant, additional advantages include instrumentation over a shorter distance (one above and one below the fracture) and no need for further operative procedures to implant or remove posterior implants. Due to their superior stiffness in axial and torsional load, the broad dynamic compression plate and the Armstrong NRC plate appear to fulfill most nearly the ideal attributes of an anterior spinal implant for the treatment of burst fractures of the throacic and lumbar spine.

The fracture of the tibial plafond or pilon fracture is an uncommon but difficult fracture to manage. Fracture of the plafond occurs when the talus is driven into the tibia from axial compression. The type of fracture that occurs will depend on the position and rotation of the foot at the time of impact. Historically, these fractures have been treated in a number of manners, but the best results have occurred when stable internal fixation is accomplished using plates and screws. Basic steps in reconstruction are restoration of anatomic length of the fibula with plate fixation, reconstruction of the tibial articular surface, cancellous bone grafting of the metaphyseal defect, and buttress plating either anteriorly or medially of the distal tibia. If anatomic reconstruction of the joint surface can be restored and stable fixation achieved, early motion of the ankle is made possible. This early motion reduces stiffness of the ankle and will yield the most satisfying results.

Case History: A 20-year-old female admitted to the hospital complaining about a vague mild pain in her left knee joint area. She first noticed the pain several months ago without impact on her daily activities. Physical examination was unremarkable for knee joint effusion or swelling, deformity or activity limitation. She denied any history of injury to the knee. Laboratory test was normal for inflammation or rheumatoid.

We treated 112 fractures of the tibia by manipulative reduction, reaming of the medullary canal, and fixation of the fracture fragments with an intramedullary nail. Seventy-six of the fractures were acute, and eight of these were second or third-degree open fractures. The other thirty-six fractures had a non-union, osteotomy for malunion, or failure of other types of treatment. Follow-up of 100 fractures showed union in all but one, which was in a drug abuser who had an amputation due to infection. The main complication was infection, which was successfully treated in six of seven fractures. The method of treatment, employing either closed or open technique and recently making use of interlocking bolts to stabilize one or both principal fracture fragments on the nail, is an excellent one for unstable acute fractures and for secondary procedures in fractures that are not associated with infection. The infection rate was increased with the open surgical technique. The few contraindications to its use are described.

Slippage of the upper femoral epiphysis can occur in association with multiple endocrine imbalances. This report documents the second case of primary parathyroid adenoma with hyperparathyroidism and symptomatic concomitant slipped capital femoral epiphyses. In the evaluation of children with slipped capital femoral epiphysis, care must be taken to eliminate other treatable disease states that are known to be associated with this phenomenon. The capital femoral physes in this child with hyperparathyroidism promptly closed following removal of the parathyroid adenoma.