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PubMed1994

Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons.

The system of Gustilo and Anderson for the classification of open fractures is commonly used as a basis for treatment decisions and for comparison of the published results of treatment. The reliability of this classification system was tested on the basis of the responses of 245 orthopaedic surgeons to a survey. The respondents were asked to provide data about their age, type of practice, and type of training; the number of open fractures of the tibia that they treated each year; and their use of the Gustilo-Anderson classification system. They were also asked to classify twelve open fractures of the tibia on the basis of a series of videotaped case presentations. Each case presentation on the color videotape included demographic data on the patient, a history of the injury, the results of the physical examination, the appearance and dimensions of the open wound before the operation, preoperative radiographs, and selected portions of the operative débridement with narration. The level of agreement for the classification of each fracture was determined according to the largest percentage of observers who chose a single classification type. The average agreement among the observers for all twelve fractures was 60 percent. The over-all agreement for each fracture ranged from 42 to 94 percent. The average agreement in the subgroup of surgeons who were considered to have the least experience (residents and fellows) was 59 per cent (range, 33 to 94 percent).(ABSTRACT TRUNCATED AT 250 WORDS)

Fractures, Open↗
PubMed1995

[Transcutaneous po2 measurement in follow-up of severe soft tissue injuries of open fractures].

The transcutaneous assessment of tissue oxygenation has become an useful method in evaluating microcirculatory disorders in different diseases. In this clinical experimental pilot study the impact of compound fractures on tissue oxygenation was examined. Using a special probe placed directly into the muscle, tissue oxygenation was measured at the site of tissue injury as well as at one non-injured site within the same fractured extremity. Furthermore, also one non-injured extremity was measured as a control. At the injured site tissue oxygenation was significantly increased during the first 4 days after trauma as compared to the non-injured extremity (40.7 +/- 1.8 mmHg vs. 23.5 +/- 4.1 mmHg). At the same time the non-injured site of the fractured extremity appeared to be significantly less oxygenated as compared to the noninjured extremity (13.2 +/- 2.3 mmHg vs. 23.5 +/- 4.1 mmHg). After day 4 until the end of the study (day 10) a complete return to normal values was noted at both sites. In conclusion it is most likely that due to a change of microcirculation within the fractured extremity the injured site is temporarily oversaturated by oxygen combined with lacking oxygenation at the non-injured site. As the microcirculatory status may be important in making decision in trauma surgery (e.g. whether or not to amputate) the method of transcutaneous oxygen measurement is a practical and useful method in trauma care.

Adolescent↗
PubMed1995

Open fractures of the arm in children.

We describe the results of treatment of open fractures of the humerus, radius and ulna in 61 children. Most were due to low-energy trauma and were rarely associated with head or other injuries; 72% were Gustilo type I, 15% type II and 13% type III. Fifteen children (25%) had open diaphyseal, supracondylar or T-shaped fractures of the humerus. Arterial injuries occurred in two (13%) and nerve injuries in 7 (47%). All nerve injuries recovered spontaneously. The long-term results in 13 children were excellent or good in 11 (85%) and fair in two (15%). Forty-six children (75%) had open forearm fractures. Arterial injuries occurred in one (2%), nerve injuries in five (11%) and a compartment syndrome in five (11%). Ruptured radial and ulnar arteries and median and ulnar nerves were repaired in one child. All other nerve injuries resolved spontaneously. Early compartment release in five children prevented Volkmann's ischaemic contracture. Normal union occurred in only 36 children (78%). Delayed union, nonunion, malunion and refracture frequently complicated type-II and type-III fractures of the shafts of the radius and ulna. The long-term results in 38 children were excellent or good in 33 (87%), fair in 4 (11%) and poor in one (2%). The short-term results for open fractures of the humerus were better than for open fractures of the forearm, but the long-term results were similar being excellent or good in 86% of the children.

Adolescent↗
PubMed1990

[Primary stabilization of open fractures of the lower extremity with the interlocking nail--the results of a study of 91 patients].

The authors report on a series of open fractures (Type I and Type II) on the lower extremities of 91 patients, treated at the I. University Clinic of Traumatology, Vienna and at the Traumatologic Department of Wilhelminenspital, Vienna from 1975-1987. There were 25 open femoral- and 66 open tibial fractures. We have seen 60% Type I and 40% Type II fractures on the femur as well as on the tibia. 74% of the patients were male. The patients' ages ranged from 15 to 92 years with a median of 32 years. The main fracture type was the comminuted fracture with over 50%. In contrast to the references in the literature (9, 11, 21) we noticed an infection rate of only 1.2%. 96% of the operated and checked up patients received bone union with the interlocking nail. We cannot in any way attribute these results solely to the used implant. Conscientious indication in the application of the interlocking nail, an exact preoperative management with prophylactic antibiotic as well as an excellent operative technique are also taken into consideration. The choice of the static interlocking nail (73%) after the closed reduction (80%) of these open fractures is supposed to be a measure against infection. Due to these results we are of the opinion that the interlocking nail when selectively used in the hands of an expert can be recommended not only in closed fractures but also in Type I and II open fractures of the femur and the tibia as long as the special principles of treatment are not neglected.

Adolescent↗
PubMed1990

Management of open fractures of the ankle joint.

A total of 64 patients with open fractures of the ankle were reviewed to assess the benefits of rigid primary internal fixation. Of these, 27 patients were treated by rigid primary internal fixation; the remainder were treated by a combination of internal splintage with K-wires and plaster casting. Patients who were treated by rigid primary fixation fared better in terms of joint mobility, maintenance of reduction and reduced sepsis rate. An interesting observation, in some of the displaced fractures, was the presence of débris far removed from the site of the wound. This was obviously sucked in during the mechanism of the injury. This has not been described previously. A method of decontaminating such wounds is discussed.

Adolescent↗
PubMed1987

A double-blind clinical trial of prophylactic cloxacillin in open fractures.

In 100 patients with first-, second-, and third-degree open fractures, a randomized, double-blind study was carried out to compare prophylactic cloxacillin and placebo. Prophylaxis was started preoperatively and continued for 10 days. The standard fracture treatment consisted of operative stabilization, mostly by means of plates or external fixators. In the cloxacillin group two infections were observed as compared to 12 in the control group. This difference was significant.

Adolescent↗
PubMed1994

The management of open fractures associated with arterial injury requiring vascular repair.

Seventy-two open fractures associated with arterial injury requiring vascular repair (Gustilo type IIIC injuries) were treated at the University of Louisville from May 1983 and through 1992. The involved anatomic areas were the humerus (four), forearm (ten), femur (eight), tibia (31), ankle (ten), and foot (nine). Fracture management consisted of careful débridement, wound irrigation, fasciotomy, and fracture stabilization. Additionally, 40 wounds (55.6%) were treated with the supplemental use of local antibiotics (tobramycin-PMMA bead chains). Twenty-three patients (32.1%) underwent primary amputation, and 49 (67.99%) of the injured vessels were repaired. There were seven secondary amputations because of infection or poor revascularization, resulting in an overall amputation rate of 41.6%. The wound infection rate was 13.9% (10 of 72) and the rate for osteomyelitis was 4.2% (3 of 72). The local use of the antibiotic bead chains was of significant benefit in lowering infectious complications. Primary coverage of soft-tissue defects with free tissue transfer had an infection rate of 66%; temporary wound coverage with the "antibiotic bead pouch" technique until wound closure can be obtained in a sterile and viable environment appears to be a better option.

Adolescent↗
PubMed2006

The management of open fractures.

This is a review of Medline and PubMed articles on open fractures published in the English literature between 1945 and April 2005. The emphasis of most published articles has been placed on definitive treatment of these injuries at sophisticated referral hospitals. The prehospital emphasis has been on rapid evacuation and referral to ensure that definitive treatment can be initiated as quickly as possible. Little has been discussed about the management of these injuries in remote settings where evacuation may consume considerably more time. Contemporary recommendations for management of these injuries are reviewed.

Fractures, Open↗
PubMed1994

Open fractures of the femoral shaft.

In this article, the treatment of open fractures of the femoral shaft is discussed, and the available clinical studies are reviewed. A rationale for treating these types of fractures is provided, and specific recommendations are made.

Bone Plates↗
PubMedDate not supplied

Epidemiology and management of open fractures of the lower limb.

Epidemiological analysis indicates that 40% of open fractures occur in the lower limb and that the tibial and femoral diaphyses are most commonly affected. Recent advances in fracture stabilization and soft tissue reconstruction technique have improved the outcome of these fractures.

Amputation, Surgical↗
PubMed2002

Vascularized composite tissue transfers or open fractures with massive soft-tissue defects in the lower extremities.

From 1982 to 1998, we treated 39 patients with type IIIB and IIIC fractures in the lower extremities by vascularized composite tissue transfers. Thirty-four of the lesions affected the lower leg, and 5 the foot and ankle. The peroneal flap was used in 25 cases, the latissimus dorsi musculocutaneous flap in 12, the scapula flap in 1, and the gracilis muscle flap in 1. In cases with a peroneal flap transfer, 18 cases used osteocutaneous flap with a fibula. Postoperative circulatory disturbances resulted in revision surgery in 9 patients. Eventually, grafting was successful in 37 patients. In patients with a lower leg reconstruction, additional bone grafting was performed in 7 of 16 patients with cutaneous or musculocutaneous flap transfers. No patient with osteocutaneous flap transfers required an additional bone grafting. The mean periods between injury and time to bone union were 11.7 months in patients with cutaneous flap transfers, and 7.5 months in patients with osteocutaneous flap transfers.

Adolescent↗
PubMed1991

Ipsilateral open fracture of the femur and tibia treated using the dynamic ASIF-BM tubular external fixator: case reports.

Two cases of ipsilateral open fracture of the femur and tibia treated using the dynamic ASIF-BM tubular external fixator are described. Results were very good, with short periods of occupational disability. These cases support primary stable osteosynthesis of these simultaneous fractures and the value of dynamic axial external fixation as a definitive treatment of open fractures of the femur and tibia shaft, either isolated or simultaneous.

Accidents, Occupational↗
PubMedDate not supplied

Open fractures of the tibia and femur in children.

Forty-seven children with 32 open tibial fractures, 11 open femoral fractures, and six closed tibial fractures with compartment syndrome, which were surgically opened, were assessed for the time to union and incidence of nonunion and infection. Treatment varied with fracture severity and patient age. Tibial external fixators were supplemented by short-leg casts, and fixators were removed at an average of 7 weeks. No child required further surgery to achieve union. There was one (2%) delayed union and no nonunions. Three fractures (6%) developed infections. No pin-tract infections occurred in tibial fractures treated with external fixation with casting. The relation between age and time to union was statistically significant. In open fractures without segmental bone loss or soft-tissue loss requiring major reconstruction, bony healing can be expected within 6 months.

Adolescent↗
PubMed1997

Open fractures of the humerus treated with external fixation.

Twenty-three patients with open fractures of the humerus who had been treated with immediate external fixation were reviewed retrospectively. Eighteen patients had adequate followup and were included in this study. Four patients (22%) had Gustilo and Anderson Grade I injury; 1 (5%), Grade II; and 13 (72%), Grade III (1 IIIA, 2 IIIB, and 10 IIIC). Fourteen patients (78%) had associated neurologic injury, of which 9 involved multiple nerves. A unilateral external fixation frame with half pins proximal and distal to the fracture site was used in all but 1 case. In 8 patients (44%) with distal humerus fractures, the external fixator crossed the elbow joint. All upper extremities in this series were salvaged. The duration of external fixation averaged 11 weeks. Complications included 3 malunions, 1 delayed union, 8 (44%) pin tract infections, 2 pin tract sequestrum formation, and 2 late fractures after removal of the external fixator. At followup (average, 34 months), function was rated as good or excellent in 12 patients (70%). There were 1 fair and 4 poor results. External fixation of complicated fractures of the humerus allowed associated injuries to the nerves, arteries, and soft tissues to be treated adequately while maintaining skeletal stability.

Adolescent↗
PubMed1975

Intramedullary nailing in the treatment of open fractures of the tibia and fibula.

Intramedullary nailing of thirty acute displaced open fractures of the tibia and fibula resulted in union with only one superficial infection. The low incidence of sepsis is attributed to the use of the curved malleable Hodgkinson tibial nail which requires no reaming, renders the operation less difficult and traumatic, and interferes minimally with bone vascularity. Fibular nailing was an effective means of stabilizing nine of the twelve fractures close to the ankle joint.

Adolescent↗