The halo brace in unstable fractures of the cervical spine: a review of 14 cases

A series of 14 patients with unstable fractures of the cervical spine, treated initially with skull traction and a few days later with a halo-thoracic brace, is described. Nine of the injuries were fractures of the odontoid process and the rest were at various levels. No patient with major neurological defects was included in the halo brace treatment. The halo brace provides significant advantages, including immediate mobilization with less time in hospital and less nursing. The results of the present series are encouraging; stable conditions were achieved in all cases.     

Blunt abdominal trauma in patients with multiple injuries

A study has been made of 61 patients with multiple injuries who also sustained closed abdominal trauma which required surgical treatment. These patients were admitted to the Department of Orthopaedics and Traumatology at the University Central Hospital, Helsinki, during the period 1969–1970. Over 60 per cent of the injuries were the result of road accidents and most of the victims were men under the age of 40. Thirty-nine of the patients were operated upon within 4 hours of admission to hospital. The abdominal organs most frequently damaged were the spleen, liver, and bladder. The total mortality reported in this series was 25 per cent.     

The results of operative and non-operative management of tibial fractures.

A series of 160 fractures of the tibia in 155 patients is analysed. Eighty patients were operated on' intramedullary nails were used in 33, AO plates in 29 and screws in 18 cases. In the final evaluation the result was classified as good in 39, fair in 27, and poor in 14 cases in the non-operative group, and 40, 25 and 15 in the operative group. Fracture comminution had a significant effect on foot and ankle motion.     

Nissen fundoplication. Results at 10 year follow-up

Between 1970 and 1973, 94 patients underwent Nissen fundoplication for gastroesophageal reflux; 60 of the 94 patients returned for follow-up study in 1982. The same surgeon operated on all the patients, and another physician who did not participate in the treatment interviewed the attending patients. Four patients (7 percent) had persistent symptoms, 7 patients had recurrent symptoms (in 3, during the first postoperative year, and in four, 2 to 10 years postoperatively), and 47 (78 percent) had postfundoplication symptoms which were moderate in most but disturbing in some. Some technical details in the performance of the fundoplication could reduce the frequency of the fundoplication symptoms. Because recurrent symptoms may appear late, even 10 years or more after operation, a definitive evaluation of the results of Nissen fundoplication is impossible to perform.     

Surgical treatment of acromioclavicular dislocation: a review of 39 patients

Results after the operative treatment of 39 total (Type III) acromioclavicular (AC) dislocations are reported. The operation consisted of suture of the acromioclavicular and coracoclavicular ligaments and transfixion of the AC joint with an AO/ASIF malleolar screw passed through the acromion into the lateral end of the clavicle. The screw was removed at an average of six weeks after the operation. In 36 patients re-examined after a mean of 4 years, the overall results were good in 92 per cent of cases. The range of flexion and abduction was excellent (over 170 degrees) in 90 per cent. Stress radiographs revealed persisting subluxation of the AC joint in 6 patients and persisting dislocation in 1. Signs of osteoarthrosis were seen in 4 patients and signs of osteolysis in 12. Radiological signs of osteolysis correlated well with incongruity of the AC joint but not with the clinical function. Radiological signs of osteoarthrosis in the AC joint, however, correlated with a poor clinical result: all patients with a fair or poor clinical result had signs of osteoarthrosis in the AC joint. Except for one, all patients returned to their preoperative occupations within an average of two months.     

The alcohol factor in accidents

The effects of a limitation of the sale of alcohol on accidents was analysed. A statistically significant drop was established in the number of patients admitted at week-ends, and the number of heavily intoxicated patients decreased very much. Significant decreases were noted in cases of murder, manslaughter, and assault and battery, and in accidents at industrial and building sites.     

Internal fixation in patients with multiple injuries

The hypothesis is advanced that there are additional and exceptional indications for the use of internal fixation in the patient with multiple injuries. Eleven case studies of patients who sustained major injuries support this hypothesis.     

Malleolar fractures treated with rigid internal fixation and immediate mobilization

Twenty-eight consecutive patients with displaced malleolar fractures were treated with anatomically exact open reduction, rigid internal fixation and immediate postoperative exercises, following the principles of the Swiss ASIF group. There were no operative or postoperative complications. One patient had a minor abscess over a loosened screw, while 1 patient developed pes equinus that required treatment. At follow-up 2 to 12 months after the operation, 25 patients were walking normally. The movements of the ankle joint were excellent or good in 25 patients. The method is recommended.     

Tibial shaft fractures treated by rigid internal fixation: the early results in a 4-year series.

Ninety-nine fractures of the shaft of the tibia in 98 patients were treated by rigid internal fixation over 4 years. One patient died after operation from myocardial infarction; and one patient went abroad. The healing course of the remaining 97 fractures is described, classified according to the type of fracture and the accuracy of operative reduction. Seventy-five fractures had a normal time to union, defined as the lasting achievement of full weight-bearing within 4 months. In 7 fractures the healing period was moderately delayed (full weight-bearing being achieved in 4-6 months) and in 5 it was seriously delayed, requiring 6-11 months after injury. Nonunion occurred in 4 cases and refracture in 6 cases. Osteitis developed in 2 cases and was successfully treated with antibiotics within 6 weeks. A second internal fixation was necessary in 12 patients. In 5 patients a plaster cast was applied to treat delayed union. Amputation was necessary in a 75-year-old man with senile dementia who developed infection after a second operation for refracture. One patient still has a pseudarthrosis after 2 years and 2 further operations. In the other 95 fractures union was the end-result. Of the 21 comminuted and open fractures only 13 healed within 4 months. We recommend a different approach in the treatment of badly comminuted and open 'high-energy' fractures. With this reservation, we find that the method of rigid internal fixation which we employ has given satisfactory early results. The frequency of both delayed healing and infection is reasonably low compared to the results in similar series.     

Two episodes of clinical fat embolism following multiple fractures.

Second episodes of clinical fat embolism have not previously been reported. This paper presents the case report of a patient with multiple fractures who developed two distinct attacks with a symptom-free interval. The second attack was partly responsible for death, and histological examination confirmed the diagnosis.     

Treatment of pseudarthrosis of the clavicle

Twelve patients were operated on between 1974 and 1979 for painful pseudarthrosis of the clavicle. The time from the injury to the operation ranged from 4 months to 12 years. We used an AO plate fixation and cancellous bone graft.The patients were able to return to work within 2 months on average. The AO plate was removed 8 to 12 months after the operation. At the 1 year follow-up all the pseudarthroses had consolidated and the patients were satisfied with the result of the treatment.     

Comminuted displaced fractures of the patella

A series of 64 comminuted displaced fractures of the patella is reviewed. Morphologically the fractures can be classified into three groups reflecting the mechanism of injury and the degree of soft tissue damage. All fractures were operated on. Tension band wire was used in 21, partial patellectomy in 33 and total patellectomy in 10 patients.The problem of the management of these fractures is often in making the choice between excision and internal fixation. In this retrospective analysis the results of anterior tension band wire fixation were acceptable even in severe comminuted fractures. Partial excision showed satisfactory results provided that at least three-fifths of the patella could be preserved. Total excision is sometimes clearly unavoidable but should be preceded by sober contemplation whenever considered as the alternative to internal fixation.     

The influence of timing and rigidity of internal fixation on bony union of fractures of the forearm

Sixty-one patients with fractures of the shafts of both bones of the forearm treated by internal fixation were studied retrospectively. The importance of the rigidity of the fixation and the time that elapsed before operation was investigated. Eight cases of non-union and one of delayed union were noted after fractures which had been operated on during the first week by non-rigid internal fixation. On the other hand, in the group of rigidly fixed fractures, the time of operation was not found to have a statistically significant effect on the healing process.     

Septic dislocation of the hip after internal fixation of trochanteric fractures

Infection of the hip joint is described in three patients after nail-plate fixation of trochanteric fractures. This led to subluxation of the joint in one case and to dislocation in the other two. None of the patients walked again. Attention is drawn to the difficulty in diagnosis and the poor prognosis of this uncommon complication of operating for hip fracture.     

Double or multiple level fractures of the spine

Over a period of 5 years, 231 patients with non-pathological fractures of the spine were admitted to the Orthopaedic Department of Athens University. Eighteen (7.79 per cent) were found to have double or multiple level fractures of the spine which means that these injuries are not so uncommon. We define double level fractures as those which are separated by an intact spinal unit, not related at least at one end to a fractured vertebra. These fractures, if overlooked, may cause serious complications.     

Avoidance of avascular necrosis of the femoral head, following fractures of the femoral neck, by early reduction and internal fixation

Clinical, experimental and post-mortem studies suggest that avascular necrosis of the femoral head following fractures of the neck of the femur, is due to compression, torsion, stretching or rupture of the blood vessels by displacement of the fragments. If this is true then urgent reduction and internal fixation are important in the prevention of this complication. This study shows that those cases which were submitted to early reduction and internal fixation had a reduced incidence in severity of avascular necrosis compared with those in whom operation was delayed. Therefore it is proposed that fractures of the femoral neck should be treated by early reduction and internal fixation.     

Cardiac contusion in the patient with multiple injuries

We have treated 20 patients with multiple injuries and concomitant myocardial contusion. The diagnosis of myocardial contusion was based mainly on serial ECG tracings which showed arrhythmias, dynamic ischaemic patterns or conduction disturbances. The clinical and laboratory findings of cardiac contusion are sometimes indistinguishable from those found in multiple injuries. Furthermore, they are overshadowed by the overt manifestation of cerebral, thoraco-abdominal and skeletal injuries. Awareness and prompt diagnostic measures are essential in the diagnosis of cardiac injury. Strict cardiac monitoring following multiple trauma will prevent serious or even fatal outcome of cardiac injury.     

Early intramedullary nailing of femoral shaft fractures: A cause of fat embolism syndrome

Results of our retrospective review of 100 consecutive patients show that early intramedullary nailing can be accomplished in severely injured patients without increasing the risk of fat embolism syndrome. No cases of fat embolism syndrome were seen after immediate (less than 24 hours) intramedullary nailing of femoral shaft fractures. In contrast, five cases of fat embolism syndrome were found in the patients treated in the traditional manner with initial balanced skeletal traction and delayed intramedullary nailing. There was a trend toward more pulmonary complications in the immediate group. This is attributed to the greater severity of injury present in the patients selected for immediate intramedullary nailing (injury severity scores 23.2 in immediate group; 12.4 in delayed group). The incidence of critical hypoxemia in the immediate group was equivalent to that in another group of injured patients who did not have fractures, but who did have similar injury severity scores.     

A universal snap-fit endoprosthesis for the treatment of subcapital fractures of the femur: a preliminary report

A new endoprosthesis for the treatment of subcapital fractures is described. It is hemispherical with a high density polyethylene (HDP) core which is snap-fitted onto a Charnley-type femoral prosthesis. The aim is to prevent acetabular erosion by its virtual lack of movement of the cartilage-metal interface. If this should occur then conversion to a total hip is readily performed without removing the femoral stem. So far 14 have been inserted without any complications. In fact, they are easily mobilized with very little pain.