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PubMed1989

Treatment of femoral shaft fractures with the Hoffmann external fixator in prepuberty.

Twenty-two children with femoral shaft fractures, between the age of 10 and 14 years, were treated with the Hoffmann external fixation apparatus from 1980 to 1985. This method of treatment is very simple. It requires less surgical exposure and allows earlier ambulation and easy nursing care. In addition, it makes patients comfortable in multiple trauma conditions. The average time to union and removal of fixators was 72 days (range, 44 to 80 days). There were no deep wound infections, nonunions, or rotationary deformities. On followup, all patients regained the range of motion of knee joints in 3 months without significant leg length discrepancy or radiographic evidence of growth disturbance. The device may serve as an alternative method for femoral shaft fractures in prepuberty, especially in areas of tropical climate.

Adolescent↗

PubMed1990

A physiologic basis for the provision of fuel mixtures in normal and stressed patients.

It has been suggested that lipid is a preferred fuel in stressed patients. We evaluated glucose oxidation in 20 patients (sepsis, cancer of the colon, multiple trauma, controls) while they received TPN (5.65 mg glucose/kg/min). Respiratory quotient (RQ) was measured by indirect calorimetry and the percent VCO2 arising from the oxidation of glucose was measured using [U-14C] glucose. Since RQs were 1.0 or greater in all patients, the nonprotein energy utilized by them was calculated to be derived completely from glucose. However, the kinetic data showed that glucose contributed only 55-60% of the VCO2. Protein oxidation contributed less than 20% of the VCO2, as calculated from urinary nitrogen. The difference must have been derived from fatty acid oxidation. The glucose turnover that was not oxidized was presumed to be converted to lipid at an RQ of 8.6. The net oxygen consumption and carbon dioxide production from this overall distribution resulted in an RQ of about 1.0 with only 60% coming from glucose oxidation. Since all patients responded in the same manner, it appears that the proper ratio of glucose and lipid was dictated on a physiologic basis and not on the type of disease.

Adult↗

PubMed1991

Improvement of septic syndrome after administration of recombinant human growth hormone (rhGH)?

Twenty patients with generalized sepsis were studied prospectively to evaluate the effects of recombinant human growth hormone (rhGH) administration. Five patients had developed sepsis after major abdominal surgery, 15 patients after multiple trauma with head injury (HTI-ISS 38 +/- 2 and Glasgow Coma Scale 4 +/- 1). The urea production rate (UPR) could be significantly reduced by the intramuscular administration of 1.5 IU of rhGH/kg bodyweight (BW) per day (UPR day: 5, 62 +/- 6.7 gm/d vs. UPR day: 10, 42.6 +/- 5.9 gm/d). The catabolic index of Bistrian (BI) was significantly lower after rhGH therapy on day 10 compared to day 5. IGF-1 increased significantly after the administration of rhGH. The nitrogen balance, however, did not become positive, despite the administration of rhGH. The changes in sepsis were estimated by the scoring system according to Elebute and Stoner on days 3, 5, 7, 10, and 13. In those patients who were available for post-treatment evaluation the parameters had returned to baseline values after the withdrawal of rhGH. Results indicate that this therapy might ameliorate the nitrogen intake, but has no influence on the course of sepsis. Compared to previously published results in nonseptic patients, the somatomedin inhibitors as well as the split-products of the complement system and the metabolites of arachidonic acid may have been responsible for this weak effect of rhGH and IGF-1 in septicemia.

Adult↗

PubMed1991

Primary intramedullary nailing of open femoral shaft fractures.

The cases of 60 patients with 63 open femoral fractures treated by primary reamed intramedullary nailing were retrospectively reviewed. Twenty-two were classified as Type I open fractures, 26 as Type II and 15 as Type III open fractures by Gustilo's classification. All fractures were treated by wound debridement followed by immediate reamed intramedullary nailing. There were five early soft-tissue infections and three late deep infections. Of the late infections, only one was osteomyelitis (1.6%). There were three nonunions and seven malunions. All of the complications were dealt with effectively by standard methods. We concluded that primary reamed intramedullary nailing is an effective alternative for the treatment of Type I and II open femur fractures and for Type III open femur fractures associated with multiple trauma.

Adolescent↗

PubMed1993

First experience and complications with the long Gamma nail.

Treatment of proximal femoral fractures is difficult. A retrospective analysis of 92 patients treated with a custom-made extended gamma nail with a mean follow up of 4 months is presented. The early results of this new method are promising. The indications for the use of the long gamma nail were intertrochanteric fractures with extension to the subtrochanteric region, imminent and pathologic fractures of the intertrochanteric and subtrochanteric region, mostly in elderly patients, proximal femoral fractures, and combination injuries in multiple trauma patients and delayed unions. In 67 cases the patients were primarily treated with a long Gamma nail. In 25 cases the nail was used after the failure of initial treatment. Complications occurred in 32 patients; however, 88 patients were able to walk at the end of the study. The advantage of this new method is that with a closed surgical technique full weight bearing directly after the operation is achieved. The long Gamma nail provides a procedure by which most complex fractures in the proximal femur can be managed.

Aged↗

PubMed1994

Pulmonary reaction during intramedullary fracture management in traumatic shock: an experimental study.

Immediate nailing of shaft fractures in severely injured patients causes fat embolization. This method therefore is considered potentially dangerous, since fat intravasation in association with multiple trauma and subsequent endotoxemia might lead to pulmonary dysfunction. We therefore studied the pathophysiologic events of intramedullary nailing in the lungs of sheep with chronic instrumentation including lung lymph fistula. In the 7 animals in group I closed nailing of the intact tibia and femur was performed. Group II (n = 7) animals sustained hypovolemic shock and retransfusion prior to nailing, while group III (n = 11) animals were treated like those in group II and further challenged on the following two days with endotoxin. Group III was compared with group IV (n = 6), in which endotoxin was given only once without additional trauma. Nailing in group I led to a significant increase of the MPAP from 10.8 to 13.8 mm Hg postoperatively (p < 0.05), but no increase in lung permeability. Only additional hypovolemia, retransfusion and nailing as performed in groups II and III showed significant increase of the lymph flow (QI) from 4.4 mL/h to 12.4 mL/h and the protein clearance (Pclear) from 3 to 6.3. A significant difference of the pulmonary permeability between group I and II was only observed postoperatively. There was no difference in the lung response between group III and IV. This ovine study corroborates that although nailing causes a moderate increase in pulmonary pressure, it does not lead to increased lung permeability. Only additional hemorrhagic shock, even when adequately resuscitated, leads to lung disturbance postoperatively. The subsequent endotoxin challenge does not aggravate lung injury.

Animals↗

PubMed1998

Abdominal compartment syndrome.

The ACS is a clinical entity that develops from progressive, acute increases in IAP and affects multiple organ systems in a graded fashion because of differential susceptibilities. The gut is the organ most sensitive to IAH, and it develops evidence of end-organ damage before the development of the classic renal, pulmonary, and cardiovascular signs. Intracranial derangements with ACS are now well described. Treatment involves expedient decompression of the abdomen, without which the syndrome of end-organ damage and reduced oxygen delivery may lead to the development of multiple organ failure and, ultimately, death. Multiple trauma, massive hemorrhage, or protracted operation with massive volume resuscitation are the situations in which the ACS is most frequently encountered. Knowledge of the ACS, however, is also essential for the management of critically ill pediatric patients (especially those with AWD) and in understanding the limitations of laparoscopy. The role of IAH in the pathogenesis of NEC, central obesity co-morbidities, and pre-eclampsia/eclampsia remains to be fully studied.

Abdomen↗

PubMedDate not supplied

Alternative therapies for arthritis treatment. Part 2.

Although modern medicine has been successful in managing infection and saving victims of multiple trauma, healthcare providers have offered little relief to individuals with chronic diseases, such as arthritis. Many patients with arthritis are seeking help with disease management from alternative therapies. When used along with allopathic medicine, these therapies may, in fact, increase quality of life for patients with arthritis. This article, second in a two-part series on alternative therapies, returns to the seven fields of practice identified by the National Institutes of Health (NIH) to explore additional treatment options for individuals with arthritis. Part 1 in this series was published in the September/October 2003 issue of Orthopaedic Nursing.

Arthritis↗

PubMed2002

Reactive thrombocytosis alone does not affect the patency of microvascular anastomosis in the splenectomy rat.

Vascular thrombosis is a harbinger of failure in microsurgery. However, there is still controversy regarding the correlation of the complications of thrombocytosis and thrombosis. Some evidence indicates that patients with elevated platelet counts tend to have a higher flap failure rate, and surgeons usually hesitate to operate on patients with thrombocytosis. Nevertheless, the authors have experienced successful free tissue transfer in seven patients with thrombocytosis resulting from traumatic splenectomy or multiple trauma. On the basis of clinical observation, the authors investigated whether reactive thrombocytosis contributes to the patency of a microvascular anastomosis. In a rodent splenectomy-induced thrombocytosis model (n = 40), stable reactive thrombocytosis occurred after postoperative days 5 to 10, with the peak on postoperative day 7. Femoral artery division and reanastomosis was performed in rats with or without splenectomy-induced thrombocytosis, and vascular patency was assessed. Platelet counts and platelet activation were studied in correlation to microvascular patency. Platelet activation as demonstrated by CD62P expression on platelets was not significantly different between rats with and without thrombocytosis (6.41 +/- 0.95 percent versus 4.51 +/- 0.55 percent, respectively; p = 0.089). As immature platelets were not increased (2.86 +/- 0.33 percent versus 1.99 +/- 0.32 percent, p = 0.074), it seems that the splenectomy-induced thrombocytosis is the result of redistribution of platelets instead of an increase in bone marrow production. There were no significant differences in the patency rates or perfusion units of femoral artery after arterial anastomosis between rats with and without thrombocytosis (90 percent and 95 percent, respectively; p = 0.561). In conclusion, this study demonstrates that microvascular anastomosis can be performed safely in patients with reactive thrombocytosis without platelet activation.

Anastomosis, Surgical↗

PubMed1985

Review of multiple traumatic injuries in an urban pediatric population.

In an urban children's hospital setting, 95 consecutive multiple trauma admissions over a five-year period were classified by the Modified Injury Severity Scale (MISS) system. As previously designed, the MISS represents a numerical consolidation of the Abbreviated Injury Scale and Glasgow Coma Scale. Our data support the accuracy of the MISS scoring in predicting the outcome of the injured child. Detailed examination of our experience with hepatic (n = 33), splenic (n = 13), and renal (n = 38) injuries, in light of recent developments, reaffirms the efficacy of selective, conservative (nonoperative) management in the majority of abdominal solid organ injuries in children. A brief epidemiologic review of urban pediatric trauma follows.

Adolescent↗

PubMed1979

Intravenous metronidazole therapy for Bacteroides fragilis meningitis.

A 69-year-old man developed meningitis due to Bacteroides fragilis and Streptococcus MG-intermedius, which progressed during chloramphenicol and nafcillin therapy to the extent that he seemed near death, with frank pus covering the spinal cord at surgery. Treatment with intravenous metronidazole and penicillin G was curative. After multiple trauma, a 20-year-old man developed meningitis due to Escherichia coli and B fragilis. He failed to respond to chloramphenicol alone, but responded to combined treatment with chloramphenicol and metronidazole. The right frontal sinus and epidural space abscesses were drained and a right frontal lobe abscess was excised. Metronidazole may be a uniquely effective agent for treatment of meningitis due to susceptible strains of Bacteroides fragilis.

Adult↗

PubMed1991

Odontoid fractures treated by anterior odontoid screw fixation.

While odontoid fractures are common injuries, disagreement exists regarding treatment. Some authors claim a high rate of pseudoarthrosis and have therefore recommended early posterior fixation and fusion. This, however, results in decreased cervical rotation. Therefore, it has been recommended that a more direct approach to the fracture be taken. Results on anterior screw fixation in 14 patients are reported. The technique was found to be especially useful in multiple trauma patients, patients who refuse halo treatment, and in some nonunions.

Bone Screws↗

PubMed2002

Upper thoracic spinal cord injury without vertebral bony lesion: a report of two cases.

STUDY DESIGN: Case report. OBJECTIVES: To describe a rarely reported type of upper thoracic spinal cord injury without vertebral bony lesion in two cases with multiple trauma. SUMMARY OF BACKGROUND DATA: Because it is supported by the stiffness of the rib cage, the upper thoracic spine has greater stability than the cervical and lumbar regions, and thus its fracture or fracture dislocation is less frequent. Nevertheless, when fracture or fracture dislocation of upper thoracic spine occurs, spinal cord involvement and severe concomitant injuries are frequently associated. METHODS: Two cases who were suspected to have thoracic spinal cord injuries were referred to our emergency center: a 19-year-old girl presented with paraparesis after her motorcycle collided with a truck, and a 63-year-old male involved in an industrial accident presented with paraplegia. RESULTS: Radiograph and computed tomography scan showed no abnormality or dislocation in the vertebral bodies in these two cases, although the upper thoracic spinal cord injuries were suspected by clinical features. Magnetic resonance images detected abnormal signals, suggesting spinal cord injuries, and these signals each emanated from levels that coincided with the observed clinical features. CONCLUSIONS: Transient subluxation or displacement might have caused the upper thoracic spinal cord injuries after the support of the rib cages was temporarily lost on application of excessive force, although such findings could not be confirmed by imaging procedures.

Accidents, Occupational↗

PubMed1996

The effect of methylprednisolone on myocardial beta-adrenergic receptors and cardiovascular function in shock patients.

The effect of methylprednisolone on the myocardial beta-adrenergic receptors after long term ( > 72 h) catecholamine infusion was studied. In 56 patients with pulmonary arterial catheter, 10 mg/kg of methylprednisolone was given as an intravenous bolus. Significant increases could be seen in cardiac output and blood pressure in patients who were simultaneously treated with vasopressors like dopamine and/or dobutamine. In patients who were on dopamine infusion higher than 10 micrograms/kg/min methylprednisolone there was an increase in the systemic vascular resistance. Patients who were not on vasopressors but received methylprednisolone, had no similar changes in hemodynamic parameters. In an in vitro analysis of tissue from the myocardium in 12/56 patients who succumbed and in four additional patients who expired after multiple trauma, a beta-adrenergic receptor assay was performed. It was found that the long term infusion of catecholamines decreased the receptor number and the methylprednisolone abolished or caused the decrease to be less pronounced. In this study we could not control the selection of the patients; a randomized study needs to be conducted in the future.

Adult↗

PubMedDate not supplied

Treatment options in pediatric femoral shaft fractures.

Fracture of the femur in a pediatric patient presents special problems, and a variety of treatment options. Child abuse and neglect should be considered and evaluated. Fractures in infants (0-18 months) may be treated successfully in a Pavlik Harness. Spica casting is safe and effective in children up to about 6 years or 100 pounds, although complications can occur and careful attention to technique is important. Surgical treatment is superior in most older or larger children or adolescents, and in cases of multiple trauma, soft tissue injury, obesity or head injury. External fixation is minimally invasive, but carries a risk of malunion and refracture. Rigid antegrade intramedully nailing is possible in adolescents of acceptable size, but has a risk of avascular necrosis. Flexible nailing is minimally invasive and well suited to fractures of the central 2/3 of the diaphysis. In comminuted fractures, it may require supplemental external support. Plate fixation is stable and addresses the entire length of the femur. Soft tissue concerns due to surgical exposure can be minimized by the use of submuscular placement technique.

Bone Nails↗

PubMed2006

Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine?: a prospective, randomized study.

STUDY DESIGN: A prospective clinical trial was conducted. OBJECTIVES: To compare the results of fusion versus nonfusion for surgically treated burst fractures of the thoracolumbar and lumbar spine. SUMMARY OF BACKGROUND DATA: The operative results of surgically treated burst fractures with short segmental fixation have been well documented. There is no report comparing the results of fusion and nonfusion. METHODS: Fifty-eight patients were included in this study, with the inclusion criteria as follows: neurologically intact spine with a kyphotic angle > or = 20 degrees, decreased vertebral body height > or = 50% or a canal compromise > or = 50%, incomplete neurologic deficit with a canal compromise 50%, complete neurologic deficit, and multilevel spinal injury or multiple traumas. All patients were randomly assigned to fusion or nonfusion groups, and operative treatment with posterior reduction and instrumentation was carried out. Posterior fusion with autogenous bone graft was performed for the fusion group (n = 30), and no fusion procedure was done for the nonfusion group (n = 28). The average follow-up period was 41 months (range, 24-71 months). RESULTS: The average loss of kyphotic angle was not statistically significant between these 2 groups. The radiographic parameters were statistically significantly better in the nonfusion group, including angular change in the flexion-extension lateral view (4.8 degrees vs. 1.0 degrees), lost correction of decreased vertebral body height (3.6% vs. 8.3%), intraoperative estimated blood loss (303 mL vs. 572 mL), and operative time (162 minutes vs. 224 minutes). The scores on the low back outcome scale were not statistically significant for these 2 groups. CONCLUSIONS: The short-term results of short segmental fixation without fusion for surgically treated burst fractures of the thoracolumbar spine were satisfactory. The advantages of instrumentation without fusion are the elimination of donor site complications, saving more motion segments, and reducing blood loss and operative time.

Adult↗

PubMed2004

Low apolipoprotein A-I level at intensive care unit admission and systemic inflammatory response syndrome exacerbation.

OBJECTIVE: Examine whether a low serum level of apolipoprotein A-I at intensive care unit (ICU) admission is associated with a further increase of the number of systemic inflammatory response syndrome (SIRS) criteria. DESIGN: Prospective observational study. SETTING: A 20-bed, university-affiliated, surgical ICU. PATIENTS: Patients admitted after major surgery, multiple trauma, or acute pancreatitis without septic shock. INTERVENTIONS: We defined as the SIRS Exacerb group patients who presented a further increase of the number of SIRS criteria during their ICU stay or, in the presence of four SIRS criteria at ICU admission, those who presented a further aggravation of organ failure. Other patients were attributed to the SIRS No Exacerb group. From day 1 to 6, we measured apolipoprotein A-I, high-density lipoprotein and total cholesterol, triglycerides, C-reactive protein, procalcitonin, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist, albumin, and other nutrition-linked variables. We looked at laboratory values or factors present at ICU admission according to the two groups. MEASUREMENTS AND MAIN RESULTS: From 63 patients analyzed, 29 (46%) were assigned to the SIRS Exacerb group. Age, sex, and SAPS II and SIRS scores at ICU admission did not differ between the groups. Patients in the SIRS Exacerb group presented more often a septic event (5/29 vs. 0/34, p =.02), had a higher hospital mortality (6/29 vs. 0/34, p =.007), and had a longer ICU stay (p =.0023). At admission, inflammatory variables such as the C-reactive protein, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist plasma levels, and other lipid or nutrition-linked variables were similar between the two groups. Apolipoprotein A-I levels were lower in the SIRS Exacerb group (median [interquartile range]: 68 [56-81] vs. 84 [69-94] mg/dL, p =.028). CONCLUSION: A low serum level of apolipoprotein A-I at ICU admission is associated with an increase of the number of SIRS criteria during the ICU stay.

Adult↗

PubMed2005

Transcutaneous PCO2 monitoring in critically ill adults: clinical evaluation of a new sensor.

OBJECTIVE: In critically ill patients, arterial blood gas analysis is the gold standard for evaluating systemic oxygenation and carbon dioxide partial pressure. A new miniaturized carbon dioxide tension Pco2-Spo2 single sensor (TOSCA, Linde Medical Sensors AG, Basel, Switzerland) continuously and noninvasively (transcutaneously) monitors both Paco2 and oxygen saturation by pulse oximetry (Spo2). The present study was designed to investigate the usability and the accuracy of this device in critically ill patients. DESIGN: Prospective clinical investigation. SETTING: A 20-bed, university-affiliated, surgical intensive care unit. PATIENTS: Patients admitted after major surgery, multiple trauma, or septic shock equipped with an arterial catheter. INTERVENTIONS: The heated (42 degrees C) sensor was fixed at the earlobe using an attachment clip. Transcutaneous Pco2 (TcPco2) measurements were correlated with Paco2 values (measured using a blood gas analyzer). In addition, the differences between Paco2 and TcPco2 values were evaluated using the method of Bland-Altman. MEASUREMENTS AND MAIN RESULTS: We studied 55 patients, aged 18-80 (mean 57 +/- 15) yrs. A total of 417 paired measurements were compared. Correlation between TcPco2 and Paco2 was r = .86 (p < .01) in the Paco2 range of 24-101 mm Hg. Mean bias (+/-sd) between the two methods of measurement (Bland-Altman analysis) was 1.2 +/- 6.0 mm Hg with TcPco2 slightly overestimating arterial carbon dioxide tension. Nineteen percent of the measured values were outside of the acceptable clinical range of agreement of +/-7.5 mm Hg. CONCLUSIONS: The present study suggests that Paco2 can be acceptably assessed by measuring TcPco2 using the TOSCA Pco2-Spo2 sensor.

Adult↗