Introduction: The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable patients with head, chest, abdomen or pelvic injuries with blood loss) followed by an immediate fracture fixation (“Early Total Care”) may be associated with a secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). We present our experience experience in the treatment strategy of polytraumatized patients with femoral shaft fracture.

Patients and Methods: From 1995 to 2008 there were 137 polytraumatized patients with femoral shaft fracture treated in our hospital. The outcomes of their treatment were retrospectively analyzed in this study. Patients were grouped according the treatment strategies for stabilization of the femoral shaft fracture: Group A – 99 patients treated with early total care (ETC) - intramedullary nailing (IMN) within 24 h of injury Group B- 38 patients treated with temporary external fixation as a bridge to IMN (DCO surgery starting at 2005).

Results: The groups were comparable regarding age, gender distribution and mechanism of injury. ISS was higher in group B (DCO) – 32,2 compared to group A (ETC) – 22,6. The patients in DCO group required significantly more fluids (14,2 L) then those in ETC (8,2 L) and blood (2,2 vs 1,3 L) in the initial 24 hours. Thoracic, abdominal or head injuries were accounted significantly higher number of patients submitted to DCO group from 2005 (24,2%) compared to ETC group (12,4%). Mean operative time for External Fixators was 40 minutes, 110 minutes for IMN. There was a significantly higher incidence of ARDS in ETC group −18,2% compared to DCO group – 8,6%. The incidence of multiple organ failure (MOF) was significantly lower in DCO group – 7,4% than in ETC group – 12,1 %. There were 3 unexpected deaths and 2 cases with conscious worsening in patients with head injury in ETC group. No significant differences in the incidence of local complications were found.

Conclusions: Based on this study it seems that a significant reduction in incidence of general systemic complications (ARDS, MOF) was found in DCO group in comparison with ETC group, Changing of the treatment protocol from ETC to DCO is not associated with increased rate of local complications (pin-tract infections, delayed unions or nonunions). There is a lower complication rate in DCO Group despite higher ISS compared with the ETC Group, DCO surgery appears to be an viable alternative for polytraumatized patients with femoral shaft fracture.

Open tibial shaft fractures are the most frequent in whole skeletal trauma and the way of their treatment cause determined hesitations. Open tibial fractures present complex surgical problem on account of their cure which needs reachable approach, because of the complications which aren’t rare, and because of their influence of the final outcome. Lately, as an alternative method of the standard intramedulary nailing, limited reamed technique was established as a concept which has to minimize the negative effect of reaming and also to provide a biomechanical stability to prevent the problems of union.

The main purpose of this study is to evaluate the clinical results and complications, especially the problems of union, after limited reamed fixation of grade II and III open fractures of the tibial diaphysis.

Clinical material from the Traumatology clinic, Medical Faculty Skopje is used in the study, which is divided into two groups according the grade of injury (using modified Gustilo classification). 56 patients were examinated. The most frequent mechanism of injury was high energy trauma (80,2%). 38 patients were treated in group A and 18 in group B. The examinations were performed following the determined criteria. At all of the patients the exact protocol were conducted which included preoperative, operative (consist of two different parts: primary surgical treatment of traumatized soft tissue and bone stabilization) and postoperative part. Few parameters were examinated in the study such as: radiological evaluation (new bone formation, time of union, problems of union – delayed, male and nonunion), infection, other complications in connection with the operative treatment, additional surgical procedures and functional outcome.

Follow up period was et least 12 months.

The results from the study showed main time of union of 27,5 weeks in Group A and 32 weeks in Group B. Concerning the problems of union, delayed union was noticed at 2 (5,26%), male union at 2 (5,26%) and non-union at 1 (2,6%) patient in Group A. In Group B delayed union at 4 (22,2%), male union at 2 (11,1%) and non-union at 2 (11,1%). Superficial infection at 6 (15,7%) and deep at 2 (5,2%) patients in Group A. In Group B superficial at 4 (22,2%), deep infection at 3 (16,6%) and fistula at 1 patient. Other complications such as compartment syndrome, DVT and problems of the implants was noticed. Additional surgical procedures were performed at 11 patients in A and at 16 in B.

Functional outcome showed great percent of excellent results in both groups.

Limited reamed intramedulary fixation is safe and effective method for operative treatment of open tibia shaft fractures (especially Gr. II according Gustilo), with relatively small percent of complications particularly concerning the problems of union and excellent functional outcome.

Introduction: Fractures of the scapula are rare injuries. When they do occur, they are usually caused by high-energy trauma and some of the patients may have significant associated injuries. Most fractures are minimally displaced and amenable to nonsurgical treatment. Open reduction and internal fixation of intra-articular fractures are considered if there is a glenohumeral sub-luxation secondary to fracture or if there is an intra-articular displacement greater than 5 mm.

Patients and Methods: This study consisted of 33 Pts from Israel and Macedonia (28 M, 5F, 18–74 year old, mean 43.5Y) followed for 2–5 years (mean 3.5Y). Fractures were classified according to Idelberg following analysis of plain radiographs and computerized radiographs. 26 patients had undisplaced or minimally displaced fractures of the glenoid and were treated conservatively by collar and cuff for three weeks, then followed by physiotherapy. The remaining seven patients had comminuted fractures with marked displacement of the glenoid and some degree of shoulder subluxation and were treated surgically. Six patients were treated by open reduction and osteosynthesis by rigid plates (3) or by screws alone (3). The 7^th patient who was treated surgically, a 73-year-old female, had a displaced fracture of the glenoid associated with comminuted fracture of the proximal humerus. She was treated by internal fixation of the fractured glenoid by 2 screws, followed by hemi-arthroplasty of the shoulder. All patients were evaluated by the Constant’s Shoulder Score and by radiographs.

Results: Overall results were excellent and good in 27/33 Pts (82%). They were almost free of pain and most of them had almost complete ROM of the affected shoulder. In the group of the patients treated conservatively for undisplaced or minimal displaced fractures of the glenoid 22/26 (85%) had satisfactory results. Five of the patients treated surgically (71%) had excellent and good results, with some better results in less comminuted fractures. The remaining 2/7 Pts treated surgically had fair results. One of them had a comminuted fracture of the glenoid and the other patient had an associated compound fracture of the proximal humerus and a shoulder hemiarthroplasty.

Conclusions: Based on this study it seems that most fractures of the glenoid – undisplaced or minimally displaced – can be treated conservatively. However, for patients with displaced glenoid fractures, best results can be obtained with open reduction and internal fixation by screws or by plates. This should be followed by intensive physiotherapy.

Anterior spinal pathology of the upper thoracic (T2–T4) segment is rare. The surgical approach is still controversial. Anterior week approach with partial osteotomy of the sternum or high latero-posterior thoracotomy are insufficient to approach this segment.

The purpose of this study is to present our experience with sternotomy as a approach in the surgical treatment of anterior spinal pathology to the upper thoracic (T2–T4) segment.

Material and methods: Between 2000–2004 nine patients with anterior spinal pathology in the upper thoracic segment were surgically treated. From all patients 5 were male and 4 female. The age ranged from 52 to 62 years. The anterior spinal pathology localisation was in 5 patients in T2; in 2 pt. in T2 and 2 pt. in both T2 and T3. The diagnosis in all patients was done by protocol wich included: careful neurological examination; standard radiographic films (AP and lateral view); CT; MRI; bone scan and other routine investigations. Neurologic status (deficit) was evaluated by modified Frankel Scale (M.F.S.). There were one patient grade A2; 4 patients with grade B; 3 pt. as a grade 3 and one grade D1. Sternotomy as a approach was used in all patients to expose the upper thoracic (T2–T4) segment. Corpectomy, extirpation of the local tumors mass; decompression of the spinal canal and neural elements was done.

The defect between T1-T3-4 was bridged with three-cortical iliac crest bone graft. In 7 cases fixation with anterior plate was done. Histologically in 2 pt. was found metastasis of carcinoma of thyroid grand foliculocellulare type; in 4 pt. solitary plasmocytoma; in two pt. giant cell tumor and in one patient invasive chondroma. All patients after surgery were transferred to the Oncology Center for other aditional treatment. Neurological recovery was registered in all patients expect one who died 2 months after surgery. The patient with grade A2 and one of grade B recovered to grade D1; one patient of grade B recovered to grade C and two of grade B and patients of grade C and D recovered to grade E. The solid fusion happened in all patient expect one who died.

Conclusion:

Sternotomy is a safe approach to the upper thoracic T2–T4 segment with possibility of direct visualisation of pathologic process and radical extirpation of the tumorous mass.

Pelvicring disruption (PRD) requires considerable forces and usually occurs in polytraumatized patients(pt).

The purpose of this study is to analyze radiologic results and functional outcome of PRD in polytraumatized pt.

Material and Methods: Of 226 pt with PRD, 78% (176) were polytraumatized, and they are the subject of this study. Mean age was 38.8 years (11.4–85.8). There were 102 men and 74 women. The cause of injury in 69% was traffic accident; fall from a great height in 16.4%; accident at work in 8.6% and miscellaneous in 6%. The incidence of involvement of other systems was: musculosceletal-78%; respiratory-58%; CNS-51%, intestinal-32%, urinary-14%; cardiovascular-8%. The average ISS was 34; 56 pt (32%) were haemodynamically unstable. According to M. Tile’s classification, 101 were found type B (B1-48; B2-30; B3-23) and 75 type C (C1-49; C2-18; C3-8). Perioperative mortality was 6% in B-type and 15% in C-type fractures.

Immediate resuscitation started at admission and was followed by staged treatment. Life-saving surgery and provisional stabilization of pelvis were performed as a top priority (first stage). Management of associated lesions (second priority) was the next stage. The last stage was open reduction and internal fixation of PRD in 102 pt, external fixation in 46 pt and combined fixation in 28 pt.

Results: X-ray follow-up results were excellent in 66%, good in 16%, fair in 10% and poor in 8%.

The best X-rays results were in type B1-94%; B2/B3-76% and C-63%.

Functional results were excellent in 48%, good in 32%, fair in 12% and poor in 8%. The best functional results were in type B2/B3 -90%; B1-73% and C-70%.

Conclusion:

Determination of priorities of surgery is essential in the management in polytraumatized patients with PRD especially in the early period.

Introduction: Hemorrhage in pelvic trauma may be life treatening. Emergent treatment obtaine the haemostasis and stop the bleading. The deþnitive treatment depend on the type of fractures and general state of patient. The purpose: of this study is to present our experiance in emergent and deþnitive treatment of pelvic disruption. Materials and methods: From 1982 to 2000, 212 pt. were treated with pelvic disruption. Of all pt. 186 were surgicaly treated with deþnitive stabilization. The other 26 pt. died. Of all pt. 72% were polytraumatized and 30% haemodinamically unstable. The average of ISS was 31. Assessment of pelvic instability was made by protocol which included: physical examination; radiographic assessment and CT of the pelvis. Classiþcation of the pelvic disruption was done according M. Tile. There were found 104 pt. with type B (B1-44; B2-37; B3-23) and 82 pt. with type C (C1-58; C2-14; C3-10). Emergent treatment of hemodynamic unstable pt. included: Intial resuscitation by polytrauma protocol, minimum diagnostic procedures, provisional stabilization of pelvis (Ex.Fx or pelvic stabilizator). Deþnitive stabilization was done by internal þxation in 87 pt., external þxation in 62 and combined þxation in 37 pt. X-rays follow-up results by Slatis were as excellent in 123 (66%); good in 33 pt. (18%); fair in 19 pt. (10%) and poor in 11 pt. (8%). Functional outcome results by DÔAubigne-Postel Scoring System were excellent in 89 pt. (48%); good in 60 pt. (32%); fair in 22 pt. (12%); poor in 15 pt. (8%). There were complication as a persistent sacroiliac pain in 12 pt.; impaired gait in 10 pt.; deep infection in 4 pt. and pin tract infection in 14 pt. Conclusion: Provisional stabilization of pelvic disruption should be viewed as part of pt. resuscitation. The results supports the deþnitive treatment of internal þxation in all type C pelvic fractures and pt. with severely type B injury.