Objectives

The most prevalent disorders of the shoulder are related to the muscles of rotator cuff. In order to develop a mechanical method for the evaluation of the rotator cuff muscles, we created a database of isometric force generation by the rotator cuff muscles in normal adult population. We hypothesised the existence of variations according to age, gender and dominancy of limb.

Background: Fractures of the distal radius are among the most common fractures encountered.

In the US these fractures account for 20% of all fractures treated at emergency care units. Methods for fixation of distal radius fractures include: casting, external fixation devices, plating, and percutaneus pinning.

In the prospective, randomized study by Strohm et al., the results of conventional Kirschner wire osteosyn-thesis were compared with those of a modified Kapandji method (“intrafocal pinning”). The functional and radiographic results of the Kapandji method were superior to those of the other technique.

We utilized a modification of the Kapandji method on a broad spectrum of distal radius fractures, including intra-articular fractures. The primary results and current follow up are presented.

Materials and Methods: 14 patients were treated. Fractures were classified according to Frykman’s classification system, ranging from Frykman’s 1 to 8. The inclusion criteria were all distal radius fractures, which had failed an initial closed reduction. Reduction was accomplished by inserting Kirschner wires percutaneusly through the fracture (intrafocal pinning) and utilizing them as levers to reduce the fragments. The wires were then advanced to be anchored in the proximal cortex. Additional wires were inserted after reduction, through the distal and proximal fragments. The forearm was fixed in a short cast for six weeks after which the Kirschner wires were removed and wrist motion exercise begun. Results were judged according to:

Roentgenographic appearance (early post op, and at follow up) according to the text book reduction criteria.

Results: Follow-up duration was 3–19 month. Reduction was graded “good” in 11 cases and “fair” in the remaining 3. All fractures united. Time to union was 4–9 weeks. Fracture reduction was maintained until union, in all cases. None of the patients needed an additional surgical corrective procedure. Functional results were satisfactory (with the limitations of too short follow-up in some of the cases). There were no cases of infection at pin site, deep or superficial.

Conclusions: The modified Kapandji method for percutaneus pinning of distal radius fractures is a useful tool for reduction and fixation of almost any sub-type of distal radius fractures, including intraarticular displaced fractures.

This technique has become our first choice of treatment, when closed reduction and cast fixation had failed to achieve or maintain reduction.

Recently, secondary life-threatening inflammatory reactions have been identified with molecular biological techniques in patients with multi-system injuries who were submitted to immediate or early intramedullary fixation of their fractured femora. This phenomenon was called “The second hit”, and it caused ARDS, PE, and Renal Failure.

In a consecutive series of 135 trauma patients with high energy long bone fractures, 40 had sustained multiple-injuries. All fractures were reduced and stabilized on admission by AO-Tubular External Fixation systems. After 72–96 hours, this system was converted to an hybrid-ring-tubular system, which had three dimensional stability. They commenced partial weight bearing 24 hours later, and were followed by bony union.

One patient developed DVT, none developed ARDS, PE, Renal Failure.

Superficial pin-tract infection was common, but no-deep infection and’or osteomyelitis were encountered.

With this minimal-invasive surgical technique, life threatening complications were avoided while preserving the integrity of the soft tissue envelope, the critical contributing biological factor for fracture healing.

The treatment of the multi-trauma, hemodynamically unstable patient, with pelvic fractures is a major challenge for the trauma team. The use of selective embolization, in early stage when hemodynamic instability persists despite control of other sources of bleeding, is well established. In these cases bleeding from an injured artery, cannot be controlled through indirect means such as an external fixation device, and must be directly addressed, through laparotomy and retroperitoneal packing or direct embolization of the bleeding artery. This procedure is part of the C phase of the ATLS, and therefore must be carried out in an emergency setup requiring a well trained team that can be alerted 24 hours a day. We present our experience and preferred protocol for the treatment of these complex injuries.

Material and Methods: Between the years 2000 and 2004, 732 patients with pelvic fractures were treated in our center. Of these, 11 patients with complex pelvic fractures required emergency arteriography and embolization. All the cases involved high energy injuries, eight motor vehicle accidents, two falls from height and one crush injury.

The average age was 32 (range 21 to 78). The pelvic fracture type was an anterior posterior mechanism in eight cases where the artery injured was the pudendal artery. In three cases iliac wing injury in a lateral compression or sheer mechanism, caused a gluteal artery injury. Timing of treatment: in 5 cases angiography was performed directly after an initial CT, in 4 cases the embolization was performed following an emergent laparotomy. In the remaining two cases, instability was recognized later in the course of treatment, one following amputation of a mangled leg and the second after secondary deterioration in a head injured multi-trauma patient.

Five patients went through pelvic fixation by an external fixation device, applied prior to angiography of which two were surgically applied and three were treated with a pelvic belt.

In five patients no pelvic fixation was needed either initially or definitively.

Discussion: When available angiographic embolization can be used affectively in these selected cases. Pelvic fractures can present with arterial injury even with a clinically stable pelvic ring. An arterial injury must be considered in all severe pelvic injuries regardless of the pelvic ring stability. We recommend strongly to use the belt as an intermittent way of controlling the hemodynamic instability and not to delay direct means of hemorrhage control such as laparotomy or embolization – if there is a team ready in the hospital. We must consider that the delay in treatment, short as it may be, needed for application the external fixation devices, may be crucial for the survival of the patient.