Multiple fractures of the pelvis with an unusually wide disruption of the symphysis pubis sustained in an accident shortly after childbirth: a case report,

A case of multiple fractures of the pelvis with wide separation of the pubic bones associated with other extensive injuries is reported. The diastasis of the symphysis pubis was reduced with surprising ease at operation. A pink discharge from the vagina was seen at the operation, but its significance was only clear after 3 days when the patient revealed that she had given birth to a child on the day before the accident. The soft relaxed pelvic and sacro-iliac ligaments associated with pregnancy prevented damage to the sacro-iliac joints and made it easy to reduce the disrupted symphysis.     

Open reduction and internal fixation of an acetabular fracture during pregnancy.

Fractures of the pelvis and acetabulum are common injuries in a mechanized society and frequently occur in the younger age groups. Commonly associated injuries such as hemorrhage, urethral tears, gastrointestinal injuries, and major vessel damage are well reported and well known to orthopaedic surgeons. Another less frequently reported complication of pelvic fractures is the potential association with pregnancy and subsequent childbirth. This problem was first described by Malgaigne in 1857 in his classic article on double vertical fractures of the pelvis, in which he described a 34-year-old woman with a pelvic fracture who subsequently died during childbirth. A review of the literature reveals numerous articles addressing potential problems with parturition subsequent to a pelvic fracture and several articles dealing with pelvic fractures occurring during pregnancy. The current literature on pelvic fractures during pregnancy, however, recommends only nonoperative treatment and, to our knowledge, there have been no reports of operative fixation during pregnancy. The purpose of this article is to report a case of an acetabular fracture in a pregnant woman treated with open reduction and internal fixation, who went on to carry a full-term baby and have a normal delivery.     

Recognition and treatment of uncommon carpal fractures

Fractures of the trapezial ridge, hamate hook, and pisiform are often due to isolated, direct injury, but other carpal bone fractures are seldom isolated injuries. Midcarpal fractures should stimulate a search for associated perilunate injury; distal carpal row fractures suggest carpometacarpal fracture--dislocations or subluxations. Crush injury with fracture of the hamate, triquetrum, or trapezium may indicate an axial subluxation of the ulnar or radial carpus. Bone scans can be useful as a screening tool. Diagnosis will often require special radiographic techniques such as tomography. Carpal bone fractures are usually intra-articular, and treatment should be aimed at restoring joint congruity. Small extra-articular fractures and injuries to the pisiform can be successfully treated with excision.     

Avulsion injuries of the pelvis in adolescents

Avulsion fractures of the apophyses of the pelvis are common in adolescent athletes. They usually occur as a result of trauma or overuse, involving especially the anterior inferior iliac spine, anterior superior iliac spine, anterior third of the iliac crest, tuber ischiadicum, and the symphysis pubis. The majority of these injuries occur during vigorous sports, with a male preponderance. They are often mistaken for muscle or tendon injuries. History, physical examination, and radiologic modalities are often helpful in diagnosis. Treatment may vary depending on the localization of the injury and the extent of fragment dislocation, but mainly remains conservative including bed rest, medications, and rehabilitation. Some patients may require surgical treatment, though.     

Reconstructive surgery of roller injuries of the hand.

Eleven patients with roller injuries to the upper extremity are described. Nine were treated initially; two were referred for treatment within 3 weeks after injury. Six patients were injured by kneading machines in bakeries, two by hot dry-cleaning mangles, two by industrial rolling machines, and one by a transmission belt which acted as a roller. The tissue damage depends on (1) the space between the rollers, (2) the speed of the rollers, (3) the hardness of the rollers, (4) the temperature of the rollers, and (5) how violently the patient attempts to withdraw the entrapped part. Lesions may be closed, consisting of a compression of the soft tissues, which may result in skin necrosis, or a tearing and separation of the skin and soft tissues away from the deep fascia (more common on the dorsal surface of the hand), or destruction of skin and deep tissue because of burns. Closed injuries usually respond to conservative care, although decompression sometimes is necessary. Experience gained from treating these 11 patients indicates that the inexperienced surgeon often tries to replace distally based flaps. Such flaps usually die and predispose to deep infection. If the condition of the wound permits, primary skin grafts should be applied; but if the bed is of poor quality, skin grafting can be delayed for several days. If it is necessary to protect exposed deep structures, they should be covered with immediate pedicle flaps. It is better to use skin from an uninjured area for a free skin graft than to use the avulsed skin as a graft. Distant flaps should be used if secondary reconstruction is anticipated. In circumferential skin loss, a combination of pedicle skin and free skin grafts is better than encircling the part with a pedicle flap. The thumb and radial fingers should be preserved, but the ulnar fingers are expendible in severe injuries. By amputating parts of fingers, reconstruction often is simplified.     

Fatal road accidents in Birmingham: Times to death and their causes

The intervals between injury and death in the 254 fatalities after road traffic accidents in Birmingham during 1969 and 1970 were analysed and correlated with other data. Sixty-three per cent were pedestrians and 23 per cent were passengers and drivers of vehicles. In round figures, about a third of the series died within half an hour, a half by 2 hours, two-thirds by 24 hours, and three-quarters by 2–4 days. The patterns of survival-time could be divided into three phases. There was an early steep decline, with 36 per cent dying during the first half-hour and 44 per cent within 1 hour of the accidents. This was followed by a longer stage during which the rate of dying decreased progressively in logarithmic fashion. The cumulative tolls were 51 per cent by 2 hours, 58 per cent by 4 hours, 68 per cent by 24 hours, and 83 per cent by 7 days. The curve then flattened into a prolonged tail. Between 7 and 28 days another 10 per cent died, making 93 per cent by 28 days. The remaining 7 per cent succumbed during the subsequent weeks and months, 3 patients surviving longer than a year.

Fifty-six per cent of vehicle occupants and 40 per cent of pedestrians died within an hour of injury, and the excess of rapid deaths among vehicle occupants was mainly due to a higher proportion of rupture of the aorta. All the ruptured aortae in vehicle occupants occurred after accidents at night or the early hours of the morning. Many of the affected drivers and passengers had consumed alcohol and their injuries were more rapidly lethal than after accidents at other times. Serious cerebral trauma dominated all groups of road users and multiple injuries were common. Included among the fatality tail was a group of subjects, mainly pedestrians, with relatively modest injuries who might have survived had they not developed pulmonary embolism, respiratory infection, or other complications.     

Thoracolumbar spine fractures: Is there a problem?

Every physician who treats injured patients has a responsibility to detect and appropriately manage thoracolumbar spinal column injuries. Fractures of the thoracolumbar spine are relatively common, so clinicians must give them every consideration both to protect from secondary spinal cord injury and to appreciate the extent of the patient's injuries. Other extraspinal as well as noncontiguous injuries to the spinal column are frequently present. Unfortunately, thoracolumbar spine fractures are often missed or diagnosed late in clinical series. In an era of cost-containment, not all responsive patients require full thoracolumbar spine radiographs. In awake, alert, nonintoxicated patients with simple injury mechanisms, these fractures can be ruled out through physical examination, if the patient has no physical findings and does not have other serious injuries. However, concern has recently been raised that some patients may have "asymptomatic" fractures that may be missed without radiography. The evidence reveals that fractures are not truly asymptomatic but may be masked by other distracting injuries, making them fractures occult rather than asymptomatic. Clinicians and subsequently their patients will always be at risk if this important distinction is forgotten.     

交通伤致四肢脊柱骨折的治疗

道路交通伤中四肢脊柱骨折的发生率较高,可由多种致伤机制所致,其中以碰撞最为常见。道路交通伤中的骨折病例呈“离心”分布,多发性骨折、同侧肢体损伤和传导暴力损伤多见。交通伤的急救,首先应处理危及生命的严重合并伤与并发症,在全身情况稳定的情况下,积极处理开放性损伤与骨折。交通伤所致的骨折患者,特别是全身情况差及老年患者,采用外固定器、特别是单侧外固定器治疗是较理想的选择;应用带锁髓内钉治疗长管状骨骨折也取得了较满意的疗效。交通伤所致的骨盆骨折,早期可采用外固定器治疗,同时积极处理骨盆骨折所引起的大出血,对C型骨盆骨折待生命体征稳定后应尽早改用内固定。交通伤所致的脊柱脊髓损伤,钛合金是首选的置入材料,通常颈椎骨折宜采用颈前路钢板螺钉固定融合术,胸腰椎骨折脱位多主张经椎弓根螺钉后路固定术。     

Soft tissue injuries associated with pelvic fractures

Significant soft tissue injuries often occur as part of high-energy injuries to the pelvis. These soft tissue injuries must be recognized and considered when implementing a treatment plan if complications are to be minimized. Vigilance in diagnosing open fractures must be maintained. Patients with these injuries must be managed aggressively, because they are at high risk for complications and death. Closed pelvic and acetabular fractures also may include soft tissue injury that requires special consideration. Careful evaluation and management of the soft tissues aids in determining appropriate techniques for reduction and fixation of the associated fractures.     

四肢脊柱交通伤的救治

四肢和脊柱是交通伤中最常见的致伤部位之一。交通伤的院前救治是我国交通伤救治中最薄弱的环节,为此,应该逐步增设院前急救网点,建立院前-院内一体化创伤救治服务体系,加强院前急救员的培养训练工作。在四肢脊柱交通伤的救治中,首先应抢救危及生命的严重创伤,但同时也要兼顾骨折的及时处理。详细了解致伤机制和全面查体是防止交通伤漏诊的重要方法。在四肢交通伤骨折的救治中,特别是对多发伤伤员的急救,外固定器技术具有明显的优越性。带锁髓内钉技术治疗四肢长管状骨骨折也可取得满意疗效。骨盆骨折的早期可采用外固定器稳定骨折,同时采用髂内动脉栓塞等技术积极处理骨盆骨折所导致的大出血。在脊柱交通伤的治疗中,应考虑到脊柱的稳定性和迟发性截瘫等因素,适当确定手术适应证。椎管环形减压术可充分地解除对脊髓的压迫。颈椎骨折常可采用颈椎前路钢板螺钉固定颈椎融合手术。胸腰椎骨折脱位可实施经椎弓根后路短节段内固定手术治疗。     

Traumatic ruptures of the aorta: a clinico-pathological study

Thirty-seven subjects with traumatic ruptures of the aorta coming to necropsy between 1958 and 1975 were analysed. All had been involved in road accidents and most had suffered multiple injuries. Most had survived to be admitted to hospital, and 25 lived for up to 13 days. The ruptures can be divided into those in (a) the ascending aorta (7 cases), (b) the proximal descending aorta (25 cases) and (c) the distal descending thoracic aorta (5 cases). Ruptures of the distal thoracic aorta were confined to pedestrians and motor cyclists with local hyperextension dislocations of the spine. Occupants of vehicles suffered ruptures of the proximal descending aorta (15 cases) or the ascending part (2 cases).All tears were transverse and internal, involving intima and media. The adventitia was intact though usually haemorrhagic. Ruptures of the ascending aorta (2 drivers, 5 pedestrians) were supravalvar and 6 were on the posterior wall. With one exception, these ruptures were associated with severe chest trauma from direct impact.Ruptures of the proximal descending aorta were located 1–3 cm beyond the left subclavian artery. The tears were major in 22 subjects, some of which were circumferential, whilst others affected part of the wall. False aneurysms contained by intact adventitia had formed in those surviving more than a day. In most cases haemorrhage had tracked into the mediastinum, finally rupturing into the pleural cavities, usually the left. However, two immediate survivors died later from complications of other injuries. In 3 subjects, only small subclinical tears were present and similar small ones were found near several major ruptures. Most major and minor ruptures are above the ligamentum arteriosum and on the anterior aortic wall, indicating a mechanism involving cranially directed tension on the aorta. Thoracic injury was also common in these, but was absent in 7 cases (including 3 motor cyclists and 2 pedestrians). This suggested that at least some ruptures result from indirect forces such as body deceleration. One rupture seemed due to a blow directed upwards against the lower chest. Analysis of all road traffic deaths in Birmingham over a 2-year period showed that aortic rupture is a major cause of rapid death among vehicle occupants, and that this is related to accidents at night and alcohol consumption.     

Radiocarpal fracture-dislocations

Radiocarpal fracture-dislocations most often are caused by high-energy trauma. These difficult, uncommon injuries involve significant soft-tissue and osseous trauma, requiring meticulous reduction and fixation. The mechanism of injury is generally a severe shear or rotational insult. Anatomically, the dislocation results in disruption of the radiocarpal ligaments and, usually, both the radial and the ulnar styloid. Understanding the anatomy of the radiocarpal joint is central to understanding the osseous and soft-tissue constraints that are disrupted with a radiocarpal dislocation. Diagnosis can be reliably made on physical examination and radiographic evaluation. Radiocarpal fracture-dislocation injuries must be differentiated from Barton fractures. Associated injuries such as open fractures, neurovascular involvement, and distal radioulnar dislocations also must be taken into account. Closed reduction can be obtained relatively easily, but open reduction and internal fixation is typically necessary to ensure accurate anatomic restoration of injured bone and ligaments.     

Sacroiliac distorsion or subluxation--a medically established concept? X-ray diagnosis--bone scintigraphy

50 patients with complaints in the region of the sacroiliacal joints and the hip, but negative radiographs following injury to the pelvis were investigated by bone scan. Scintigraphic diagnosis always showed involvement of the pelvis ring other than the apparent fractures. Together with the clinical symptoms scintigraphic findings are interpreted as sacroiliacal strain or subluxation. Additional injuries to the acetabulum and to the lumbosacral joints may be present. The patients' complaints are explained, the injuries are localized and documented.     

Anterior fracture dislocation of sacroiliac joint: A rare type of crescent fracture

Crescent fractures of the pelvis are usually described as posterior sacro iliac fracture dislocations. Rarely anterior displacement of the fractured iliac fragment along with dislocation has been reported in crescent fractures. Four cases of anterior fracture dislocation of the sacro iliac joint managed in the last two years by a single surgeon are presented. The injury mechanism, radiological diagnosis, management protocol along with functional outcomes of all the four patients have been discussed. CT scan is essential in the diagnosis and preoperative planning of this injury pattern. Early fixation along with proper reduction leads to excellent functional outcome in this subset of lateral compression injuries of the pelvis.     

Sacral fractures

Sacral fractures most commonly occur after pelvic ring injuries but occasionally in isolation. Although the true incidence of sacral fractures is unknown, an estimated 30% are identified late. Sequelae of inappropriately treated or untreated sacral fractures include persistent pain, decreased mobility, and neurologic compromise. Because these fractures often result from high-energy trauma, concomitant injuries should be suspected. A thorough physical examination, including a detailed neurologic assessment and radiographic evaluation, is necessary to determine treatment. Computed tomography of the pelvis/sacrum can provide significant information about fracture pattern. Surgical intervention, often as a combination of neural decompression and stabilization, is indicated in patients with neurologic deficits, significant soft-tissue compromise, and lumbosacral instability. Patient satisfaction with surgical intervention has not been definitively documented, although neurologic improvement with timely intervention has been noted.     

Current concepts review: carpal injuries - fractures, ligaments, dislocations

An overview about current concepts in treating carpal injuries is presented. These injuries are more commonly seen in young, active individuals after a fall on an outstretched hand. Conventional radiographs and a thorough examination are important. The scaphoid is the most affected bone. Scaphoid fractures can be classified in accordance to OTA, AO, and other classification systems, but mostly to Herbert. It can be treated non-operatively if undisplaced, however a percutaneous internal fixation can be discussed to achieve earlier return to work and shorter time to union, but hazarding the consequences of an operation. Unstable, proximal pole, or delayed diagnosed scaphoid fractures should be treated surgically. Nonunion is seen in 5 - 40% of scaphoid fractures depending mainly on displacement and localization of the fracture. The gold standard in non-osteoarthritic scaphoid nonunion is debridement of the nonunion site, bone grafting, realignment, stable fixation and rehabilitation. The treatment of scaphoid-nonunion advanced collapse is more complex. Proximal row carpectomy or arthrodesis (four-corner or complete wrist) can be mandatory. Other carpal bone fractures are rare. Perilunate dislocations are also uncommon but can be disabling. They usually originate in high-energy trauma. The Mayfield stages help to understand the injury pattern. Open reduction through both volar and dorsal approaches, repair of the volar capsule as well as volar and dorsal ligaments, and internal fixation is commonly the standard treatment. However osteoarthritis and carpal instability are often encountered.     

Treatment of radial head and neck fractures: in favor of anatomical reconstruction

Radial head fractures represent the most common elbow fractures. Undisplaced fractures usually occur in isolation and can be treated nonsurgically. Displaced fractures should be treated surgically. Simple two-part fractures can easily be handled by osteosynthesis, but comminuted fractures pose a major problem for reconstruction. As the radial head is an important stabilizer of the elbow joint??especially in the context of concomitant ligamentous injuries??its resection may lead to pain, limited range of motion, and instability. Therefore, radial head resection is not recommended for the acute situation and open reduction internal fixation (ORIF) or prosthetic replacement should be aimed for. Complications such as secondary loss of fixation, radial head necrosis, and nonunion due to insufficient stability of the osteosynthesis have often been described. Therefore, prosthetic replacement is recommended if stable reconstruction is impossible. With the development of new locking plates especially designed for the maintenance of radial head fractures, the indications for osteosynthesis may be extended. As radial head fractures are complicated by a high percentage of ligamentous injuries and concomitant elbow fractures such as the coronoid, capitellum, and proximal ulna, these additional injuries have to be taken into account. The current treatment concepts are discussed within this paper.     

Complications of pelvic fractures from blunt trauma.

Significant external forces are required to fracture a normal pelvis. These forces usually result from rapid deceleration or crushing injuries, and energy often is delivered to multiple anatomic sites in addition to the pelvis. Associated injuries are common, and numerous complications can occur in patients with pelvic fractures. During 4 years, the authors treated 144 men and 92 women with pelvic fractures from blunt trauma who were admitted directly to the University of Mississippi Medical Center. They had a mean age of 31.5 years, a mean Injury Severity Score of 21.3, and an average hospital stay of 16.8 days. Seventy-seven of the 236 patients (32.6%) had 137 complications, including 18 deaths. Most of these were infections such as pneumonia (6), urinary tract infections (8), wound infections (8), or sepsis without a defined source (10). There was a high incidence of pulmonary complications including Adult Respiratory Distress Syndrome (12), significant atelectasis (7), and fat emboli (3). Musculoskeletal complications (13) and coagulopathy (12) also occurred frequently. Eight patients had thromboembolic events, but prophylactic, subcutaneous heparin was not beneficial in preventing these complications. Patients with complications had higher Injury Severity Scores, lower Trauma Scores, increased transfusion requirements, longer hospital stays, and greater hospital charges compared to those without complications (P less than 0.01 for all variables). There was no association of complications with patient age, sex, mechanism of injury, anatomic site or amount of displacement of the pelvic fracture, or vector of injury. Patients with unstable pelvic fractures were much more likely to have complications than were those with stable pelvic fractures (P = 0.013).(ABSTRACT TRUNCATED AT 250 WORDS)     

Study on characteristics of fractures from road traffic accidents in 306 cases

OBJECTIVE: To investigate the characteristics of bone fractures from road traffic accidents and analyze their injury mechanisms so as to provide reference for the research and medical care of traffic trauma. METHODS: Three hundred and six patients with fractures from road traffic accidents were included into this study. A total of 507 fractures were identified and the injury mechanism, location distribution and frequency were analyzed. RESULTS: The most common location of fractures was the lower extremities, followed by the upper extremities, skull and maxillofacial region, and the rarest was the spine. A total of 56% of the patients suffered from multiple fractures. The fractures of the patella, femur and pelvis and the fractures of the olecranon, humerus and shoulder often happened simultaneously. CONCLUSIONS: The injury mechanisms can be classified into four types: impact, incoordinate movement, stretch injury and crush and extrusion. The fractures from traffic accidents have the following characteristics: centrifugal distribution of the injuries, multiple fractures, force transmission and ipsilateral occurrence.     

Traumatologie der Wirbelsäule

Spinal trauma poses considerable threats to survival and quality of life. Especially cervical spine injuries are often associated with neurologic deficits. A thorough diagnostic pathway, often including computed tomography with sagittal reconstruction, is mandatory to evaluate the extent and consequences of spinal trauma. Every treatment must aim to restore stability and prevent secondary neurologic deterioration. Compression fractures usually can be treated successfully with conservative treatment, while burst fractures usually, and flexion/distraction injuries, and fracture-dislocation generally require internal stabilization. Injuries of the upper cervical spine can be treated conservatively or operatively, depending on the degree of instability. In the lower cervical spine, most injuries require internal fixation.