The management of acute trauma to the upper extremity includes the urgent treatment of injuries and the timing and choice of surgical stabilization and reconstruction. To evaluate and treat severe upper extremity trauma, the orthopedic surgeon should understand the principles of the emergency department and operating theater management of commonly seen traumatic injuries to the distal humerus, elbow, forearm, wrist, and hand. A review of the principles for treating these complex injuries, including principles of soft tissue coverage, will aid surgeons in achieving the goal of providing optimal treatment for their patients.
Unstable intertrochanteric fractures in elderly patients are associated with a high rate of complications and poses difficulty in fixation. Cemented calcar replacement hemiarthroplasty may be a suitable treatment in these patients. The aim of this study is to assess the clinical and functional results of the use of such a prosthesis in old patients with an unstable intertrochanteric fracture of the femur.
Thirty patients were included in this prospective study, mean age 66 years. All the patients had unstable intertrochanteric fractures. Only patients with type III, IV, or type V fractures according to the Evans’ classification were included in the study. Functional and radiological results were assessed after a mean follow-up period of 22 months.
At the end of the study, only 24 patients were available for evaluation. The mean follow-up period was 22 months (range, 18–36 months). At the last follow-up, the mean Harris hip score was 85 points. Radiologically, all stems were stable, without significant changes in alignment or progressive subsidence. No infection or thromboembolic complications were encountered.
Cemented bipolar hemiarthroplasty with calcar replacement is a good option for unstable intertrochanteric fractures in the elderly. It allows early weight bearing and rapid return to prefracture activity and does not have the difficulty and complications of internal fixation of this complex fracture.
Despite the application of modern locking plate technology, complications remain common after fixation of proximal humeral fractures in elderly patients. Varus deformity and intra-articular hardware are most often responsible; fortunately, both of these complications can be avoided. Recent advances in imaging, reduction techniques, fixation methods, and postoperative care have made surgical outcomes more reliable. Particular attention should be paid to obtaining high-quality fluoroscopic images, avoiding varus reductions, supporting the osteoporotic humeral head, using appropriate screw length, using tension band sutures liberally, and protecting the construct postoperatively. Using these methods, many proximal humeral fractures in patients older than 75 years can be fixed reliably.
Numerous pelvic osteotomies for the treatment of developmental dysplasia of the hip have been described.
To compare the outcome of two types of pelvic osteotomy, Salter and Dega, for the treatment of late-diagnosed developmental dysplasia of the hip.
This prospective study included 32 patients (36 hips), 18 girls and 14 boys, mean age 2.3±0.5 years. Patients were randomized for management with Salter or Dega pelvic osteotomy after open reduction and capsulorrhaphy with or without femoral shortening osteotomy. The Salter osteotomy group included 19 hips and the Dega osteotomy group included 17 hips. The median follow-up period was 12 months (range 9–20 months).
We achieved an overall success rate of 88.9% in the 36 hips, with no significant difference between the two techniques (89.5% in the Salter group and 88.2% in the Dega group, P=1.000). Both techniques achieved comparable reduction of the acetabular index (20.3±9.0π in Salter vs. 22.0±8.9° in Dega group, P=0.565). There was no significant difference in the center-edge angle between the two groups (34.8±13.0° in the Salter group and 37.4±12.1° in the Dega group, P=0.554).
We achieved comparable results with Salter and Dega osteotomy. The latter has a further advantage of avoiding a second surgery required in the Salter technique to remove hardware.
In the Hoffer technique, the tendons of the latissimus dorsi (LD) and teres major (TM) muscles are transferred to the rotator cuff posterior to the long head of the triceps muscle, which significantly improves external rotation and abduction range of motion in the shoulders of children with obstetric brachial plexus palsy (OBPP) with internal rotation contracture.
Ten children with OBPP C5/C6 pattern were included in the study and underwent simultaneous subscapularis recession and transfer of the LD and TM tendons to the rotator cuff through a single posterior incision. The age at the time of surgery ranged from 3 years and 3 months to 14 years and 1 month, with an average age of 7 years. The age at initial evaluation ranged from 1 year and 6 months to 9 years and 8 months, with an average of 5 years and 11 months.
There was significant improvement in the degree of active shoulder abduction, from a mean 72° (range 40–90°) preoperatively to 136° (range 90–180°) postoperatively. The preoperative passive shoulder external rotation averaged from 78° (range 0–100°) to 64°. The postoperative active external rotation ranged from 0 to 90°.
Transfer of LD and TM tendons through a single incision to the rotator cuff significantly increases the degree of abduction and external rotation in children with OBPP having internal rotation contracture.
The treatment of fractures of the distal tibia is associated with high complication rates. Diabetes mellitus places patients at an increased risk for complications following distal tibia fractures whether treated conservatively or surgically. However, this risk is specific to patients with comorbidities of diabetes. There has been debate on the ideal method for the treatment of these patients because much of the literature has highlighted the extremes of potentially poor outcomes. Less invasive techniques for realignment of distal tibial fractures and reduction of the articular fragments using an Ilizarov fixator with or without minimal internal fixation have been recommended as reliable and safe methods for the treatment of these patients.
Between June 2008 and January 2012, 25 patients with type II diabetes mellitus receiving oral and/or insulin for blood sugar control, with complicated distal tibia fractures, were treated using an Ilizarov fixator. All patients presented within 6 months from their primary treatment in other centers. Fifteen patients were treated conservatively in a cast or braces. Ten patients were treated surgically. All patients presented with nonunited fractures and 22 patients had varus malalignment. Ten of the 15 patients who were treated conservatively had deep pressure sores. Assessment of the ankle brachial index and vascular Doppler study were used as noninvasive techniques to verify the vascularity in the affected limb.
In all patients, the fractures healed, with no need for any procedure to enhance healing. All patients were followed up for 12 months after fixator removal. The average time in an external fixator was 18.1 weeks (average12–22 weeks). On the final follow-up, none of the patients had a long-term sequel of infection. Malunion with less than 5π varus occurred in five patients. None of the patients developed Charcot neuroarthropathy or required amputation during the treatment or at the final follow-up. Long-term bracing for up to 6 months after frame removal was required in five patients with varus malalignment and in the patient who had a proximal fracture.
Diabetic patients with recent or complicated distal tibia fractures having one or more diabetic comorbidities, but with good peripheral vascularity and continuous control of blood sugar level, they can be treated using an Ilizarov external fixator with a lower complication rate than open reduction and internal fixation procedures and with results comparable to those of nondiabetic patients.
The incidence of posterior subluxation/dislocation of the shoulder secondary to obstetric brachial plexus palsy is found to be relatively high with increasing awareness of the condition and advances in radiological imaging. Left untreated, glenohumeral deformation and functional impairment are progressive with increasing age.
Twelve patients with posterior subluxation (five patients)/dislocation (seven patients) of the shoulder secondary to obstetric brachial plexus palsy were treated by operative reduction with concomitant anterior soft-tissue release and latissimus dorsi and teres major tendon transfers to the rotator cuff. The mean age at surgery was 3 years.
After a mean follow-up of 3 years, the mean aggregate Mallet score improved from 9.5 points preoperatively to 14.4 points postoperatively (increased by 51.6%). Abduction and external rotation improved significantly. Radiologically, the mean percentage of humeral head anterior to the midscapular line improved from 9% preoperatively to 42% postoperatively. All patients except one showed restoration of the dislocation, which was maintained until final follow-up. The mean glenoid version improved from −45.8° preoperatively to −8° at the latest follow-up.
The procedure used results in improved shoulder function and glenohumeral joint remodeling. Postoperative care and rehabilitation programs are mandatory for satisfactory outcome.