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Biomedical subjects

Steven J Morgan

Publications and source records attributed to Steven J Morgan.

At least 19 recordsLinked to original sources
PubMed2007

Utility of once-daily dose of low-molecular-weight heparin to prevent venous thromboembolism in multisystem trauma patients.

INTRODUCTION: Venous thromboembolism is a preventable cause of death in the severely injured patient. Low-molecular-weight heparins (LMWHs) have been recommended as effective, safe prophylactic agents. However, LMWH use remains controversial in patients at risk for bleeding, those with traumatic brain injury, and those undergoing multiple invasive or operative procedures. We hypothesized that a protocol utilizing once-daily LMWH prophylaxis in high-risk trauma patients, regardless of the need for invasive procedures, is feasible, safe, and effective. METHODS: From August 1998 to August 2000, all patients admitted to our American College of Surgeons-verified Level I trauma facility following injury were evaluated for deep venous thrombosis (DVT) risk and prospectively followed. Patients at high risk for DVT, including those with stable intracranial injuries, were placed on our institutional protocol and prospectively followed. Patients on the protocol received daily injections of the LMWH, dalteparin; DVT screening was performed with duplex ultrasonography within 48 hours of admission and after 7 to 10 days after injury. Regimen compliance, bleeding complications, DVT rates, and pulmonary embolus (PE) rates were analyzed. RESULTS: During the 2-year study period, 6247 trauma patients were admitted; 743 were considered at high risk for DVT. Most of the patients were men (72%), with a mean age of 38.7 years (range 15-89 years) and a mean injury severity score (ISS) of 19.5. Compliance with the daily regimen was maintained in 74% of patients. DVT was detected in 3.9% and PE in 0.8%. The wound complications rate was 2.7%, and the need for unexplained transfusions was 3%. There were no exacerbations of head injury following dalteparin initiation due to bleeding. There were 16 patient deaths; none was caused by PE or late hemorrhage. CONCLUSIONS: Once-daily dosing of prophylactic LMWH dalteparin is feasible, safe, and effective in high-risk trauma patients. Our protocol allows one to "operate through" systemic prophylaxis and ensures timely prophylaxis for brain-injured and multisystem trauma patients.

Adolescent↗
PubMed2006

Fatigue behavior of Ilizarov frame versus tibial interlocking nail in a comminuted tibial fracture model: a biomechanical study.

BACKGROUND: Treatment options for comminuted tibial shaft fractures include plating, intramedullary nailing, and external fixation. No biomechanical comparison between an interlocking tibia nail with external fixation by an Ilizarov frame has been reported to date. In the present study, we compared the fatigue behaviour of Ilizarov frames to interlocking intramedullary nails in a comminuted tibial fracture model under a combined loading of axial compression, bending and torsion. Our goal was to determine the biomechanical characteristics, stability and durability for each device over a clinically relevant three month testing period. The study hypothesis was that differences in the mechanical properties may account for differing clinical results and provide information applicable to clinical decision making for comminuted tibia shaft fractures. METHODS: In this biomechanical study, 12 composite tibial bone models with a comminuted fracture and a 25 mm diaphyseal gap were investigated. Of these, six models were stabilized with a 180-mm four-ring Ilizarov frame, and six models were minimally reamed and stabilized with a 10 mm statically locked Russell-Taylor Delta tibial nail. After measuring the pre-fatigue axial compression bending and torsion stiffness, each model was loaded under a sinusoidal cyclic combined loading of axial compression (2.8/28 lbf; 12.46/124.6 N) and torque (1.7/17 lbf-in; 0.19/1.92 Nm) at a frequency of 3 Hz. The test was performed until failure (implant breakage or >or= 5 degrees angulations and/or 2 cm shortening) occurred or until 252,000 cycles were completed, which corresponds to approximately three months testing period. RESULTS: In all 12 models, both the Ilizarov frame and the interlocking tibia nail were able to maintain fracture stability of the tibial defect and to complete the full 252,000 cycles during the entire study period of three months. A significantly higher stiffness to axial compression and torsion was demonstrated by the tibial interlocking nail model, while the Ilizarov frame provided a significantly increased range of axial micromotion. CONCLUSION: This is the first study, to our knowledge, which compares the biomechanical properties of an intramedullary nail to an external Ilizarov frame to cyclic axial loading and torsion in a comminuted tibia shaft fracture model. Prospective, randomized trials comparing Ilizarov frames and interlocked tibial nails are needed to clarify the clinical impact of these biomechanical findings.

Journal Article↗
PubMed2006

Metabolic changes after polytrauma: an imperative for early nutritional support.

Major trauma induces marked metabolic changes which contribute to the systemic immune suppression in severely injured patients and increase the risk of infection and posttraumatic organ failure. The hypercatabolic state of polytrauma patients must be recognized early and treated by an appropriate nutritional management in order to avoid late complications. Clinical studies in recent years have supported the concept of "immunonutrition" for severely injured patients, which takes into account the supplementation of Omega-3 fatty acids and essential aminoacids, such as glutamine. Yet many aspects of the nutritional strategies for polytrauma patients remain controversial, including the exact timing, caloric and protein amount of nutrition, choice of enteral versus parenteral route, and duration. The present review will provide an outline of the pathophysiological metabolic changes after major trauma that endorse the current basis for early immunonutrition of polytrauma patients.

Journal Article↗
PubMed2006

Expandable intramedullary nailing for tibial and femoral fractures: a preliminary analysis of perioperative complications.

OBJECTIVE: To report the results of using the expandable nailing system in the treatment of femoral and tibial shaft fractures. DESIGN: Prospective, cohort series. SETTING: Two level-1 university trauma centers. PARTICIPANTS: Forty-eight patients with acute, traumatic diaphyseal fractures of the tibia or femur. INTERVENTION: Internal fixation of lower extremity long bone fractures using expandable intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Perioperative complications and time to healing. RESULTS: Forty-nine long bone fractures were treated: 22 femoral fractures (OTA classification: 4 type A1, 6 A2, 7 A3, 1 B1, and 4 B2) and 27 tibial fractures (OTA classification: 4 type A1, 11 A2, 9 A3, 0 B1, and 3 B2). There were 13 open fractures and 37 closed fractures. Healing occurred in 37 (75%) fractures without additional interventions. There were 2 tibial delayed unions and 1 femoral and 1 tibial nonunion. Five tibial shaft fractures and 6 femoral fractures shortened by 1.0 cm or more postoperatively. In 3 tibias and 4 femurs, shortening occurred after fractures judged to be length-stable became unstable because of fracture propagation during nail expansion. Five tibias and 3 femurs were converted to standard locked nails because of shortening. The average time to healing, excluding nonunion, was 15 weeks in the tibia and 16 weeks in the femur. The expandable nail resulted in an unplanned reoperation in 12 cases (25%). CONCLUSION: We found a high complication rate because of shortening, which was independent of fracture classification. Consequently, we cannot recommend the use of an unlocked, expandable nail in diaphyseal fractures of the femur or tibia.

Female↗
PubMed2006

The deltoid muscle: an anatomic description of the deltoid insertion to the proximal humerus.

OBJECTIVE: This study was designed to describe the anatomic insertion point of the deltoid to the proximal humerus. DESIGN: Gross anatomic study. SETTING: Level one academic trauma center. PATIENTS: Cadaveric study. MAIN OUTCOME MEASUREMENTS: Bilateral humeri were stripped of soft tissue except the deltoid insertion point. The length of the humeri was recorded. The distance from the greater tuberosity to the proximal most aspect of the tendinous insertion point and the distal most tendinous attachment was measured. The humeri were cross-sectioned 5-mm distal to the proximal insertion point, 5-mm proximal to the distal insertion point, and midway between these 2 points. The circumferential proportion of humerus into which the tendon inserted at each point was recorded. RESULTS: The mean length of the deltoid insertion was 97 (range, 83-111) mm. The mean distance from the greater tuberosity to the proximal insertion point was 61 (range, 55-75) mm and to the distal insertion was 158 (range, 142-172) mm. The deltoid occupied on average: 8% of the humeral circumference 5 mm from the proximal insertion point, 39% at the mid point of the insertion, and 31% of the humeral circumference 5 mm from the distal insertion point. CONCLUSIONS: The deltoid insertion is long and broad. A 4.5-mm plate would result in detaching 13.5 mm of the insertion, leaving at least half of the original insertion attached to the humerus.

Bone Plates↗
PubMed2006

Concepts of transtibial amputation: Burgess technique versus modified Brückner procedure.

The technique of a long posterior myocutaneous flap described by Ernest M. Burgess in the late 1960s is one of the most frequent procedures for below-knee amputations worldwide. To account for some potential problems associated with this procedure in patients with occlusive arterial disease, Lutz Brückner developed a modified amputation technique for transtibial amputation in the 1980s. Although this new standardized procedure has been widely used in Germany, it is not well known outside central Europe, secondary to its lack of description in English published work. In this review article, we describe a comparison of the technical aspects of the Burgess procedure with the modified Brückner technique for transtibial amputations. In addition, the charts of 69 consecutive patients with end-stage occlusive arterial disease undergoing below-knee amputation by either of the two standardized procedures (Burgess, n = 29; Brückner, n = 40) were reviewed. The clinical results of the two procedures are reported and compared. Review of the German published work suggests that the two techniques for transtibial amputation in patients with occlusive arterial disease appear to have similar results. This is further supported by data from our own 10-year experience with 69 patients undergoing below-knee amputation by either of the two standardized procedures. This suggests that the Brückner technique is at least equivalent to the Burgess procedure with regard to the clinical outcome in patients with occlusive arterial disease. The potential advantages of the standardized modified Brückner procedure compared with the 'classical' Burgess technique for transtibial amputation remain to be assessed in prospective multicentre trials.

Amputation, Surgical↗
PubMed2006

Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal.

BACKGROUND: Great variability exists in methods of stabilization for syndesmotic disruptions of the ankle. We hypothesized that syndesmotic screw fixation with 3.5-mm fully threaded cortical screws through either three or four cortices would have similar strength and rate of mechanical failure and that retention of screws after fracture healing would not result in adverse clinical symptoms. METHODS: In a prospective, surgeon-randomized study at a Level-one trauma center, 127 patients with syndesmotic disruptions were treated surgically. Seven patients were lost to followup, leaving 120 for review. Syndesmotic disruptions were stabilized with 3.5-mm fully threaded cortical screws placed through three or four cortices. Screws were removed only if symptomatic. Outcome criteria were screw failure, loss of reduction, and need for hardware removal. RESULTS: Fifty-nine patients received fixation through three cortices and 61 patients received fixation through four cortices. Mean follow-up was 150 days. In the group with stabilization through three cortices, hardware failure occurred in five patients (8%) and three had a loss of reduction. In the group with stabilization through four cortices, hardware failure occurred in four patients (7%); all were asymptomatic and did not require screw removal. There was no loss of reduction in that group. Comparing the two groups using binary logistic analysis, there was no difference in loss of reduction (p = 0.871), screw breakage (p = 0.689), or need for hardware removal (p = 0.731). CONCLUSION: The data suggest that either three or four cortices of fixation can be used when stabilizing syndesmotic injuries of the ankle. There was a trend towards higher loss of reduction in the group with tricortical fixation when weightbearing restrictions were not followed. Retention of the syndesmotic screws, even with mechanical failure, does not pose a clinical problem. Weightbearing can be allowed at 6 to 10 weeks without routine removal of screws.

Adult↗
PubMed2006

Continuous infusion of local anesthetic at iliac crest bone-graft sites for postoperative pain relief. A randomized, double-blind study.

BACKGROUND: Autologous bone graft is the so-called gold standard for reconstruction of bone defects and nonunions. The most frequent complication is donor site pain. The iliac crest is a common source for autologous bone graft. The purpose of this study was to determine whether a continuous infusion of 0.5% bupivacaine into the iliac crest harvest site provides pain relief that is superior to the relief provided by systemic narcotic pain medication alone in patients undergoing reconstructive orthopaedic trauma procedures. METHODS: A prospective, double-blind randomized study of patients over eighteen years of age who were undergoing harvesting of iliac crest bone graft was conducted. The patients were randomized to the treatment arm (bupivacaine infusion pump) or the placebo arm. Postoperatively, all study patients received morphine sulfate with use of a patient-controlled analgesia pump. The patients recorded the pain at the donor and recipient sites with use of a scale ranging from 0 to 10. The use of systemic narcotic medication was recorded. Independent-samples t tests were used to assess differences in perceived pain relief between the treatment and control groups at zero, eight, sixteen, twenty-four, thirty-two, forty, and forty-eight hours after surgery. Pain was also assessed at two and six weeks postoperatively. RESULTS: Sixty patients were enrolled. Across all data points, except pain at the recipient site at twenty-four hours, no significant differences in the perception of pain were found between the bupivacaine group and the placebo group. On the average, patients in the treatment group reported more pain than those in the control group. No significant difference was found between the two groups with regard to the amount of narcotic medication used. CONCLUSIONS: No difference in perceived pain was found between the groups. The results of this small, unstratified study indicate that continuous infusion of bupivacaine at iliac crest bone-graft sites during the postoperative period is not an effective pain-control measure in hospitalized patients receiving systemic narcotic medication.

Adult↗
PubMed2005

Pelvic fracture pattern does not always predict the need for urgent embolization.

BACKGROUND: The intimate relationship between the pelvis and related vasculature can lead to life-threatening arterial hemorrhage after blunt trauma. Unfortunately, hemorrhage related to pelvic fracture is often associated with other serious injuries, complicating clinical decision making. Previous clinical reviews have associated fracture geometry with arterial hemorrhage, specifically implicating those injuries with evidence of major ligamentous disruption (MLD). METHODS: We analyzed pelvic fractures for evidence of a relationship between MLD and the need for angiographic embolization. Our trauma registry was reviewed from 1996 to 2002; 283 patients with pelvic fractures arrived in the emergency department with a systolic blood pressure < or = 90 mmHg. MLD was defined as anteroposterior compression types II and III, lateral compression type III, combined mechanism, and vertical shear according to the Young-Burgess classification. RESULTS: Thirty-seven (13%) of the patients studied required angiographic embolization for control of pelvic hemorrhage. The pelvic fracture pattern (MLD vs. non-MLD) did not differ significantly between the embolized and nonembolized groups. The predictive value of other variables varied by gender. Age had a significant correlation with the need for embolization in women, whereas Injury Severity Score did not. Conversely, age had no predictive value for men, whereas Injury Severity Score had a significant correlation. CONCLUSION: The findings in this study suggest that pelvic fracture pattern does not consistently correlate with the patient's need for urgent embolization and should not be used as the sole determinant for angiography. Furthermore, variables such as age and gender should be further investigated, as they may potentially have a predictive value in this clinical setting.

Adult↗
PubMed2005

Be prepared.

Explore the source record for details and available documents.

Disaster Planning↗
PubMed2005

Clinical evaluation of a true percutaneous technique for antegrade femoral nailing.

From July 1997 to March 2001, 209 consecutive patients with 215 femoral shaft fractures amenable to antegrade femoral nailing were enrolled. A true percutaneous insertion technique was performed using a stab wound incision. One hundred ninety-seven (92%) fractures achieved primary union with anatomic or near anatomic alignment. Eighteen (8%) healing problems and two deep infections (1%) responded to repeat interventions. There was one iatrogenic complication related to an anterior starting point. External blood loss was minimal (generally <100 cc). Incisions averaged 16 mm and healed uneventfully. At one-year follow-up only 10% of patients had hip abductor pain. The percutaneous technique appears to be a safe and effective alternative to the standard technique. Hip pain at one year appears decreased compared to reports using a traditional approach.

Adolescent↗
PubMed2004

Advantages of submuscular bridge plating for complex pediatric femur fractures.

Conventional treatments of pediatric femoral shaft fractures may result in an unacceptable rate of complications, especially in complex fractures. These fractures include high-energy injuries resulting in unstable fracture patterns, fractures in the proximal or distal third, and fractures occurring in large or multiply injured children. Our goal was to evaluate whether a minimally invasive submuscular bridge plating technique provides stability for early functional treatment (without protective casting or bracing) and predictable healing. Fifty-one patients with an average age of 10 years were studied. Sixty-seven percent had high-energy injuries and 55% had unstable fracture patterns. With an average followup of 14.2 months, all fractures united with excellent clinical results. Two (4%) significant complications occurred: fracture of one 3.5-mm LC-DCP Ti plate, and refracture of a pathologic fracture after early plate removal. Four patients (8%) had a leg-length discrepancy ranging from 23-mm short to 10-mm long. The average operative time was 106 minutes, with average fluoroscopy time of 84 seconds. Procedures were done by 15 surgeons in five university medical centers. This technique offers the advantage of adequate stability for early functional treatment and predictable healing with maintenance of length and alignment for all pediatric femoral shaft fractures.

Adolescent↗
PubMed2004

Symptoms of posttraumatic stress disorder after orthopaedic trauma.

BACKGROUND: The purpose of this study was to determine the prevalence of posttraumatic stress disorder among patients seen following an orthopaedic traumatic injury and to identify whether injury-related or demographic variables are associated with the disorder. METHODS: Five hundred and eighty patients who had sustained orthopaedic trauma completed a Revised Civilian Mississippi Scale for Posttraumatic Stress Disorder questionnaire. Demographic and injury data were collected to analyze potential variables associated with posttraumatic stress disorder. RESULTS: Two hundred and ninety-five respondents (51%) met the criteria for the diagnosis of posttraumatic stress disorder. Patients with posttraumatic stress disorder had significantly higher Injury Severity Scores (p = 0.04), a higher sum of Extremity Abbreviated Injury Scores (p = 0.05), and a longer duration since the injury than those without posttraumatic stress disorder (p < 0.01). However, none of these three variables demonstrated a good or excellent ability to discriminate between patients who had posttraumatic stress disorder and those who did not. The response to the item, "The emotional problems caused by the injury have been more difficult than the physical problems," was significantly associated with the presence of posttraumatic stress disorder (p < 0.0001) and showed a fair ability to identify patients with the disorder. CONCLUSIONS: Posttraumatic stress disorder is common after orthopaedic trauma. Patients who respond positively to the item, "The emotional problems caused by the injury have been more difficult than the physical problems," may meet diagnostic criteria for this disorder and should be evaluated further.

Adult↗
PubMed2003

Bilateral peroneal nerve palsy following emergent stabilization of a pelvic ring injury.

External noninvasive compressive devices are becoming popular for emergent stabilization of pelvic ring disruptions. The ease of application utilizing available materials such as sheets, the noninvasive nature of such measures, and perceived absence of complications has made this a popular stabilization modality. The authors report a case of bilateral peroneal nerve palsy related to the use of external compressive wraps in a patient with pelvic ring injury.

Accidents, Traffic↗
PubMed2003

Clinical effectiveness of the physical examination in diagnosis of posterior pelvic ring injuries.

OBJECTIVE: To determine if physical examination (PE) of the posterior pelvis in awake and alert trauma patients with known pelvic ring injuries can accurately predict a potentially unstable posterior ring injury and guide the use of computed tomography (CT) more effectively. DESIGN: Patients with pelvic fracture noted on anteroposterior (AP) pelvic radiographs were prospectively evaluated over a 21-month period. AP, inlet, and outlet radiographs as well as CT scans were obtained on all patients. SETTING: Level I trauma center. PATIENTS: Patients were excluded who had a Glasgow Coma Scale score less than or equal to 12, were unable to cooperate with a PE, were 12 years old or younger, or had concomitant acetabular fracture. INTERVENTION: A focused PE protocol with emphasis on the posterior pelvis, including posterior palpation of the sacrum and sacroiliac joint, AP and lateral iliac wing compression, active hip range of motion, and a digital rectal examination. If an individual PE parameter resulted in tenderness, it was considered positive. MAIN OUTCOME MEASUREMENTS: The 4 PE modalities were compared with CT scan results using sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratio, and McNemar's test for discordant pairs. RESULTS: The study group included 66 patients. Of patients, 49 (74%) had posterior pelvic injury diagnosed by CT scan. Of the patients with positive posterior CT scan findings, 48 (98%) had pain with posterior palpation. Sensitivity and specificity were 0.98 and 0.94, and the likelihood ratio was 16.3. CONCLUSIONS: PE, specifically palpation of the posterior pelvis, in patients with pelvic fractures can accurately detect injuries of the posterior ring.

Adolescent↗