Value of primary stabilization of femoral shaft fractures in patients with simple and multiple injuries

There is a variety of opinions about the optimal time when to stabilise femoral shaft fractures. The data of 100 patients were analysed in order to compare primary versus secondary intramedullary stabilisation. The rate of wound infections and of other concomitant complications was significantly lower after primary osteosynthesis which is therefore superior to secondary stabilisation in both kinds of patients--those with single and those with multiple injuries. In the group of 50 patients with immediate surgery four complications altogether were found, including one wound-infection, whereas in the group of 50 patients with delayed surgery there was a total of twelve complications, including five wound-infections and six cases of fat- and pulmonary-embolism. The average duration of stay in hospital was only 17 days after primary but 28 days after secondary surgery.     

多发伤中股骨干骨折的一期扩髓髓内钉固定

目的探讨多发伤中股骨干骨折一期扩髓髓内钉固定是否会增加并发症的发生率及死亡率。方法采用回顾性对比研究,依据下列标准选择病例:(1)年龄为14~65岁;(2)多发伤,且ISS>16;(3)住院时间不少于48h;(4)病史中无明显影响全身状况的疾病,如糖尿病,慢性心、肺、肾功能不全等;(5)有股骨干骨折,且进行了扩髓髓内钉手术,不包含外固定支架或钢板、牵引及石膏固定和非扩髓髓内钉固定者。将符合上述标准的192例按受伤至手术时间划分为两组,A组为≤24h手术者(一期扩髓组,76例),B组为>24h手术者(116例),将两组间合并伤情况、ISS、住院时间、ICU时间、并发症、死亡率及合并休克率情况进行比较。结果经统计学处理,两组的股骨开放伤发生率(A组56.6%,B组34.5%,χ2=7.545,P<0.001)、合并休克率(A组48.7%,B组31.0%,χ2=6.078,P<0.001)及住院时间[A组(16.1±6.5)d,B组(29.3±9.3)d,t=10.766,P<0.001]差异有显著性,而在其他方面差异均无统计学意义。结论在多发伤患者中,只要能控制休克,保证生命体征平稳,对股骨干骨折行一期扩髓髓内钉固定不会增加患者的并发症发生率及死亡率,可促进患者早日康复,缩短住院时间,从而减少住院费用。     

Intramedullary stabilization of humeral shaft fractures in patients with multiple trauma

Sixty-one patients with multiple injuries, which included sixty-three fractures of the humeral diaphysis, were treated by intramedullary stabilization of the fracture with Rush rods or Ender nails. Portals of entry allowing antegrade or retrograde insertion or insertion at the epicondyles were used. For most of the patients, closed intramedullary fixation of the fracture was performed within twenty-four hours of the injury. Adequate follow-up studies were obtained for fifty-six patients (fifty-eight fractures). Stabilization by antegrade insertion gave excellent results if the portal of entry did not violate the rotator cuff. Symptoms of impingement in the shoulder and pain associated with an incorrect position of the portal for antegrade insertion required early removal of the device. Each fracture that was treated with fixation through the epicondylar portal had a poor result, and this technique is not recommended. Retrograde insertion, with the portal of entry located proximal to the olecranon fossa, yielded excellent results. Care must be taken to prevent encroachment on the olecranon fossa, which can result in a block to extension of the elbow. The surgical technique of closed fixation by retrograde insertion is presented. Immediate closed intramedullary stabilization of the fractured humeral shaft resulted in a 94 per cent rate of union and a 62 per cent rate of excellent clinical results. This technique is particularly applicable to patients with multiple trauma, as it minimizes loss of blood and the risk to neurovascular structures while providing stability for mobilization and aggressive pulmonary physiotherapy. In our opinion, however, isolated fractures of the humeral shaft should be treated by non-operative methods.     

The monofixator in the primary stabilization of femoral shaft fractures in multiply-injured patients

In multiply-injured patients with femoral shaft fractures, evidence grows that a fast primary temporary stabilization device is preferable to a definitive method of stabilization by intramedullary nailing or plate osteosynthesis. Conversion to intramedullary nailing is performed later.

During a 16-month period, we treated nine patients with 10 femoral shaft fractures in this way. There were two open fractures and six other fractures were associated with severe soft tissue damage. The overall function result is excellent and consolidation was reached after a relatively short time. The advantages are clear: a shorter operation time, earlier mobilization and rehabilitation, and fewer complications.     

Incidence and risk factors of knee injuries associated with ipsilateral femoral shaft fractures: A multicentre retrospective analysis of 429 femoral shaft injuries

A femoral shaft fracture is usually a high-energy injury and, thus, is likely to be accompanied by an injury of adjacent joints such as a knee ligament injury. However, these associated injuries are often neglected because of severe pain and deformity. The purpose of the current study is to evaluate the incidence, type and risk factors of ipsilateral knee injuries associated with femoral shaft fractures.A total of 429 femoral shaft fractures were included in this study from January 2010 to September 2015. There were 320 males and 109 females, with mean age of 40.7 years (range, 15–88). Exclusion criteria were skeletally immature patients and patients with metabolic bone disease such as osteoporosis, atypical femoral fractures, and pathologic fractures. The incidence and type of knee injury were identified, and the injury mechanisms, AO/OTA classification of the femoral shaft fractures, were analysed for assessment of risk factors for knee injuries combined with femoral shaft fractures.Knee injuries were found in 131 cases. Knee ligament injuries were identified in 87 cases. There were 20 posterior cruciate ligament injuries, 11 anterior cruciate ligament (ACL) injuries, 16 medial collateral ligament (MCL) injuries, 8 lateral collateral ligament (LCL) injuries, and 32 multi-ligament injuries. In 24 cases, ligament injuries were not detected before internal fixation of femoral shaft fractures. Average time of diagnosis for ligament injury after fixation in these neglected cases was about 10.6 weeks (range, 1–32).Fractures around the knee joint were identified in 69 cases; there were 32 patellar fractures, 14 distal femoral intra-articular fractures, 14 tibia plateau fractures, 3 proximal fibular fractures, and 6 combined fractures.Male sex, type C fracture of AO/OTA classification, and motor vehicle accidents were identified as risk factors for associated ipsilateral knee injuries in femoral shaft fractures.Knee injuries were identified in approximately 30% of femoral shaft fractures. About 30% of ligament injuries were not detected before internal fixation of femoral shaft fractures. Care should be taken since knee injuries can be accompanied by ipsilateral femoral shaft fractures.     

Blood loss evaluation in children under the age of 11 with femoral shaft fractures patients with isolated versus multiple injuries

BACKGROUND: Blood loss from non-cavitary hemorrhages is a significant source of hypovolemic shock in trauma patients. It has been reported that pediatric femoral fractures do not cause excess blood loss if there is no additional injury or trauma. The purpose of this study was to define the magnitude of blood loss resulting from pediatric femoral fractures and the factors influencing the loss. METHODS: Twenty children under the age of 11 with femoral shaft fractures were included in this study. The patients' data were collected prospectively for 2 years. Hemoglobin concentrations, hematocrit levels, emergency room records, and clinical findings were evaluated and additional injuries were considered. RESULTS AND CONCLUSION: The patients with additional trauma showed significant decreases in both hemoglobin concentrations and hematocrit levels, comparison with the patients who had only isolated femoral fractures. If there is an obvious decrease in hematocrit and/or hemoglobin concentration in a child with a femoral fracture, the possibility of additional injuries should be investigated.     

Treatment of femoral shaft fractures associated with acute spinal cord injuries

Twenty-seven femoral shaft fractures in 23 patients with acute spinal cord injuries were reviewed for evaluation of the outcome of operative versus nonoperative treatment. Three groups were identified: 11 nonoperative, eight early operative, and eight delayed operative. Patients treated initially by nonoperative methods developed five impending nonunions (31%), which subsequently were treated by open reduction and internal fixation. One femur in each of the operative groups developed a refracture after early removal of metal fixation devices. In the delayed operative group, four patients (50%) required manipulation under general anesthesia for treatment of poor knee motion. Patients with complete neurologic lesions whose femurs were treated nonoperatively incurred more complications, i.e., decubitus ulcers, than those treated operatively. Operative stabilization of the femur within six weeks of injury rendered the most favorable outcome with the least number of orthopedic or medical complications in patients with both complete and incomplete cord lesions. All of the eight fractures united.     

股骨转子周围骨折并股骨中上段骨折的手术治疗

[目的]探讨应用股骨近端髓内钉配合有限切开复位钛捆绑带内固定治疗股骨转子周围骨折并股骨中上段骨折的手术方法和疗效。[方法]对2002年1月～2006年10月收治的21例股骨转子周围骨折并股骨中上段骨折的病人，均采用股骨近端髓内钉固定或配合行有限切开复位钛捆绑带内固定技术治疗。[结果]21例病人全部获得9个月～5年的随访，平均13个月，所有病例均达临床骨性愈合，未出现内固定物折断、松动、脱出等情况。患肢髋膝关节功能均恢复良好。[结论]根据病人的年龄和骨折的类型，采用股骨近端髓内钉或配合行有限切开复位钛捆绑带内固定技术是一种良好的内固定方式，具有创伤小、操作简便易行、固定牢固可靠、利于骨折愈合等优点，良好的保留了患肢的功能。技术的主要关键是在微创的前提下达到解剖复位。     

微创内固定系统治疗同侧股骨髁部和股骨干骨折

目的探讨微创内固定系统治疗同侧股骨髁部和股骨干骨折的疗效。方法对7例同侧股骨髁部和股骨干骨折的患者,均采用微创手术内固定。结果随访8-24个月,7例切口均一期愈合,X线片复查骨折对位、对线良好。膝关节功能按M erchan评分标准：优4例,良3例。结论微创内固定系统对同侧股骨髁部和股骨干骨折是有效的治疗方法,术中不需植骨,术后并发症少。     

Contributing factors affecting initial bony healing in interlocking nailings for femoral shaft fractures

The objective of this study was to evaluate bony healing and predict factors affecting bony healing of femoral fractures treated with interlocking nailing (ILN) in static or dynamic conditions, and in reamed or unreamed procedures. Seventy-four femoral fractures (69 patients) were initially stabilized with ILNs in static condition. Among these fractures, ten static ILNs were dynamized after approximately 6 (median 6.4, range 1–13) months because of poor fracture healing. Reamed ILNs were performed for 55 fractures and unreamed ILNs for 19 fractures. Clinical and roentgenograhic processes were analyzed with emphasis on whether or not ILNs were dynamized. To evaluate any significant contributing factors affecting the nonunion of femoral shaft fractures treated with ILNs, logistic regression analysis was done. The union rates of static ILNs and dynamized ILNs were 92% (59/64) and 70% (7/10) respectively, but there was no significant difference between them. Five nonunions were seen in reamed ILNs and three in unreamed ILNs. The predictive logistic regression equation for nonunion was as follows: Log 1-p/p=1.05 -1.20 × AO/ASIF fracture grade in the femur -3.07 × existence of multiskeletal trauma in lower extremity + 0.06 × age -1.11 × smoking history -0.3 × existence of polytrauma -0.626 × the severity of soft tissue injury ( p=0.002; each variable in the above equation was arranged according to the significant order). Among the variables, AO fracture grade (type C) in the femur and existence of multiskeletal trauma in lower extremity were significantly related to nonunion. Static ILN in most femoral shaft fractures does not inhibit the process of fracture healing. The following associated skeletal lesions were our concerns for nonunion and broken nail in static or dynamic ILNs: (1) C-type femoral fracture; and (2) existence of multiskeletal trauma, such as double lesions in the ipsilateral femur, floating knee injury, and bilateral femoral fractures.     

The results of plating humeral shaft fractures in patients with multiple injuries. The Sunnybrook experience

Excellent results can be achieved by plating fractures of the shaft of the humerus in patients with multiple injuries. This helps in nursing care and in the management of other injuries. In 38 patients admitted to a regional trauma centre, 39 humeral shaft fractures were plated. There were 27 men and 11 women, with an average age of 31.5 years. Fourteen of the humeral fractures were compound and 20 had significant comminution; 23 were fixed by a plate on the day of admission and all 39 by the twentieth day. Follow-up of 34 fractures showed that all had united, 33 primarily. All patients but one had a fully functional shoulder and no patient with a fractured humerus alone had lost any elbow movement. Complications were rare--one case each of non-union, fixation failure and infection. No permanent nerve injuries were produced at operation. The plating of fractures of the humerus in these circumstances has been shown to produce excellent results and has a place in the management of the patient with multiple injuries.     

Intramedullary locking nails for femoral shaft fractures in elderly patients

Fractures of the femoral shaft are generally considered to affect young patients, but we have reviewed 24 cases in patients over 60 years who have been treated by locked nailing, usually by closed methods. Most were women with low-velocity injuries, but despite this, 14 fractures were significantly comminuted. The complication rate was 54% with a peri-operative mortality of 17%. Most complications were the general ones of operating on elderly patients. Specific complications included: fractures below an abnormal hip, proximal fracture related to the nail and poor purchase in the distal femur. In all survivors, the femoral shaft fractures united satisfactorily, and the fixation allowed early mobilisation. The locking nail appears to be an effective method of managing femoral shaft fractures in the elderly patient.     

骨科损伤控制在严重多发伤合并股骨骨折治疗中的应用

[目的]探讨骨科损伤控制(damage control orthopedics,DCO)技术在严重多发伤合并股骨骨折治疗中的可行性及疗效。[方法]回顾性分析2012年1月~2015年6月诊治的多发伤合并股骨骨折患者,选取损伤严重度评分(injury severity score,ISS)≥16,存活期>24 h的47例患者为研究对象。根据不同时期手术方式不同分为两组,27例应用DCO技术进行治疗作为DCO组,20例应用早期全面处理(early total care,ETC)技术进行治疗作为ETC组。其中,DCO组中7例股骨骨折以外支架作为终极手术治疗,20例一期行外支架治疗,待患者一般情况稳定后二期采用闭合或有限切开复位方法治疗;ETC组中所有病例均采用一期闭合或有限切开复位内固定方法进行治疗。统计所有患者的ISS评分、术中失血量、手术时间、机械通气时间和并发症等指标。[结果]与ETC组相比较,DCO组患者的术中失血量、手术时间、机械通气时间和并发症等指标均明显改善。[结论]将DCO技术应用于严重多发伤合并股骨骨折的治疗,能降低创伤后的二次打击,减少并发症的发生。     

锁定加压板治疗股骨干骨折失败原因分析

股骨干骨折采用骨牵引、石膏外固定等方法治疗并发症多,长期固定影响下肢功能,目前常用的手术方法治疗股骨干骨折。锁定加压板（locking compress plate,LCP）在治疗干骺端粉碎性骨折、骨质疏松性骨折、骨干复杂粉碎性骨折以及假体周围骨折等特殊类型骨折有优势[1]。