What was the question? The treatment of multi-injured patients requires initial stabilization of general conditions and vital parameters. The first stage in orthopedic management of the fractures in trauma involves stabilization of the bone segments to reduce blood loss and allow nursing. External fixators are fast, versatile and essential in the emergency situation in cases of multiple fractures, especially with soft tissue loss. According to damage control orthopedics (DCO) concepts, it is possible to replace an external fixator (EF) with internal synthesis (ORIF) after a period of time to reduce the risks of ORIF. However, surgery can be difficult to perform and pin sites can be the source of bone infection, in which the EF as a definitive treatment option may be considered. How did you answer the question? In trauma surgery, instability of the hardware, fractures near the joint, frame extending across the knee and the ankle, initial fixation was converted to definitive treatment with circular frames according to the Ilizarov method. Fourteen patients (2 female and 12 males; age 24 to 80 yrs, average age 43,4 y/o) were treated with various circular framses as definitive treatment: Ilizarov (2), Sheffield (7), Taylor Spatial Frame (TSF) (4) and TrueLok (1) between November 2002 and December 2007 in multiply injured patients with ISS >
20. Seven cases were femoral and seven tibial. The femoral group had four knee spanning fixator configurations and three unilateral external fixators. The tibial group had 4 unilateral frames, 1 hybrid EF, 1 across the knee EF and 1 across the ankle EF. Five patients had temporary femoral and tibial hardwares in the same side. Three patients had unilateral tibial and femoral fractures. What are the results? All patients achieved consolidation. The mean duration of femoral EF was 7.6 months (5–9 months). One bone loss in a distal femoral shaft treated with Sheffield EF had lengthening (5 cm) after acute short-hening. Two patients had a gradual distal femoral fracture reduction and a mechanical axis correction by TSF. Three patients with tibial bone loss had 2 trifocal bone transport (17,5 and 9 cm) and 1 bifocal bone transport 5 cm. The TSF had no additional pre-operative planning and major post-operative frame adjustments. The intra-operative devices was easier for the TSF. What are your conclusions? Circular frame osteosynthesis following initial EF, is a reliable and effective strategy for treatment in severe open femur and tibia fractures and post traumatic reconstruction.
Hig energy fractures of the lower limb are often associated with tibial or femoral bone loss, skin exposition with vascular and nervous injuries (Gustilo et al.). The surgical procedure is a real challenge, consisting in a temporary stabilization of the fracture associated with a plastic and/or vascular reconstruction. Once the skin and vascular injuries are recovered, the orthopaedic surgeon can remove the temporary stabilization performing a circular external fixation with bone lengthening by using the “bifocal” (one site of metaphiseal corticotomy and one site of compression) or “trifocal” (two sites of metaphiseal corticotomy and one site of compression) technique. We use to do a “docking site” treatment when bone fragments are nearly in contact. Our experience indicates that circular external fixation, by using the Orthofix system, is a very useful and safe technique in the management of severe lower limb injuries. Our good clinical results lead us to suggest this surgical technique that allow to obtain a limb reconstruction, avoiding segment amputation.
Thirty-seven of 87 (42.5%) had a pelvic fracture pattern attributable to group A and 50 to group B All patients included had multiple sites of bleeding, but predominant hemorrhage from pelvic fracture was observed in 87% of group A patients and in only 6% of group B, while predominant hemorrhage from extra-pelvic sites was identified in 94% of group B and in only 13% of group A (p<
.001).
Dislocation and carpal fracture-dislocation are a rare injury, interesting capsula and ligaments, with a variable damage of the vascularization. Classification is difficult for the complexity on this lesion. The aim of our work is to underline how the best final clinical result is achieved after an immediate treatment of reduction and stabilization of bone injury. We considered two groups:
A: 8 patients, who have been observed since july ’93 until 1996 ; all the patients were men who had work or car accidents, with outstretched upper extremity. The ages of the patients ranged from 19 to 34 years.. All patients were followed for an average of 8 years B: Another group is at short term is since luglio 2002 until today and is in 10 patients with 11 wrists with a total of 14 surgical treatment 1 is bilateral 3 wrists reoperated for lacking initial reduction or for the general initial condition Assesment of the patients includeds clinical rating and roentgenografich analysis. The clinical scoring included pain, functional status, range of motion and grip strength. Among the various classifications, we took into account the one proposed by Allieu, based on the radio-lunate ligament, consequently this classification offers an important prognostic factor. In one of our cases there was assocciated a fracture of the radial stiloid, and in other one a posterior dislocation of the elbow. We treated all the patients with a volar approach, the stabilitation of the carpus and scaphoid was achieved utilizing K wires in four cases, microscrew in two patients for scaphoid’s fracture and in other one the Herbert screw in the A group In the B recent group we used in all cases K wiring, and herbert screw in 8 wrists, microscrews in one , and internal capsulodesis in the 2 last for perilunate isolated dislocation The initial failing of reduction is due to an unstable reduction in very injured patient ( we use only k wire for the navicular) 10 patients in the second B group have been treated by the same first Author After surgery treatment, the wrist was immobilizated in a splint for 6 weeks, then a careful mobilitation was started. Finally we think that is necessary, to avoid the instability and pseudoartrosis on the scaphoid, to treat all the transcapho-lunate dislocation with open reduction and stabilitation, as agreed with literature.